Nutrition

Question 1

8 year old girl with 2 months Of hair loss, normal weight and height. Otherwise asymptomatic.

A.What are 3 common causes of hair loss in children. ?

B. Then they tell you she is a vegan. what are two nutritional deficiencies that would put her at risk of hair loss?

Answer 1

A. Common hair loss 3
1. Times capitis 
2. Trichollomania
3. Nutritional deficiency
4. Chemotherapy
5. Hypothyroidism
6. Alopecia Areata
7. Telogen Effluvium
Non medical
1. Newborn hair loss
2. Friction hair loss
3. Chemicals
4. Blow-dry
5. Hair ties

B vegan
- low iron, low zinc and low protein/amino acids

Question 2

A 12 year old embarking upon a vegan diet. Which of the following is the BEST advice to give ?

A. Take vit B12 supplement
B. Take zinc supplement
C. Take vit D supplement
D. See a dietician

Answer 2

D. See a dietician

Question 3

Mother uses marijuana for chronic pain. Breastfeeding. What do you tell her about the risks to the baby:

A. Continue breastfeeding. Benefits of breastfeeding outweigh risk of marijuana
B. Marijuana is contraindicated due to risks on the developing brain
C. Recent studies on the legal use of marijuana found no risk
D. Counsel to stop using marijuana. Risks to baby are unknown
E. Call CAS

Answer 3

D. Counsel to stop using marijuana. Risks to baby unknown

Mother risk website: lactating mother should refrain from consuming cannabinoids. Advising mothers discontinue breast-feeding if they cannot stop using cannabinoid must incorporate the known risks of formula feeding. Cannabinoid exposure through milk has not been shown to increase neonatal risk, but there are no appropriate studies of this. In every case, nursing baby should be closely monitored.

Question 4

12 year old teen presents to your office and tells you she would like to begin a vegan diet. What is the best advice you can give her today.

A. Vit B12
B. Iron
C. Consult a dietician or nutritionist
D. Calcium supplements

Answer 4

C .consult a dietician or nutritionist

Question 5

What Is the recommended vitamin D supplementation for a six month old baby living above the 55th latitude during winter months?

A. 200 international units
B. 400 international units
C. 600 international units
D.800 international units

Answer 5

D. 800 international units

Question 6

What should you supplement in a baby who is being fed only goats milk?

A. Vitamin B 12
B. Folate
C. Zinc

Answer 6

B. Folate

Up-to-date: the Folate in goats milk is markedly lower than cows milk. Infants fed goats milk may develop folate deficiency especially if no other sources introduced in diet yet.

Question 7

Who should not receive soy formula due to its phytoestrogen content ?

A. Baby with galactosemia
B. Baby whose family is vegan
C. Baby with congenital hypothyroidism

Answer 7

C. Baby with congenital hypothyroidism

CPS statement: concerns for the use of soy based formula and infant nutrition.

• No toxicity from soy based formula.
• Concerns about abnormal thyroid function in infants with hypothyroidism.
• Proposed mechanism: phytoestrogens inhibit thyroid peroxidase and decrease FT4 and T3 leading to abnormal thyroid function.
• If congenital hypothyroid infant is on soy formula, must monitor TFTs
• This is not an issue for healthy kids with normal thyroid has no effect with soy Phytoestrogens

Question 8

Which of the following is higher in the milk of term mothers compared to milk of preterm mothers?

A. Carbohydrate
B. Fat
C. Protein
D. Nothing

Answer 8

Controversial

A. Carbohydrate vs B. Fat

Preterm milk is more like colostrum and there is a slower transition to full term milk. So in term milk there is less protein, more carbohydrate and more fat

Question 9

A 3 week old bottle fed baby presentsto you for the first well baby check. You recommend an iron fortified formula and mother asks about side effects. The most likely outcome:

A. No problems
B. Constipation
C. G.I. upset.

Answer 9

A. No problems

Peds and review article but I am in fortification:

There is a misconception by some health professionals and parents that infants fed iron fortified formula have more gastrointestinal distress, such as Colic, constipation, diarrhea, or gastro-oesophageal reflux. Of these constipation and irritability appear to be the most common concern. An association between iron and constipation is appealing to mothers who remember the association between taking prenatal Iron in large doses and changes in their own G.I. tract function when they were pregnant. A controlled study by Oski and a double blind crossover study by Nelson et al
Compared to iron fortified and low iron formulas and found no differences and prevalence of fussiness or cramping, Colic, gastro-oesophageal reflux, or flatulence,. Moreover, therapeutic iron up to six mg per kilogram per day given to infants was well tolerated.

Question 10

Who needs 800 IU of vitamin D ?

Answer 10

A. Breastfed Inuit baby living in the Arctic

Vitamin D does should be 400 international units a day for all infants during the first year, with an increased 800 international units a day from all sources between October and April north of the 55th parallel and between the 40th and 55th parallel in individual with risk factors for vitamin D deficiency other than Latitude alone

Question 11

A 5 year old child with spastic CPA who is known for reflux has recently started NG feeds and is doing much better growing healthy etc. What is the next step to consider

A. Jejunostomy tube
B. Gastrostomy tube
C. Fundoplication

Answer 11

B. Gastrostomy tube

Nasogastric tube’s are minimally invasive but are easily dislodged and have local complications including sinusitis, congestion, or Otitis or skin irritation. Generally nasogastric feeding should only be used for short term nutritional support less than three months. They may be useful to use for nutrition challenge to assess tolerance and efficacy. For long-term enteral nutrition support more than three months a gastrostomy should be considered. Gastrostomies are more invasive, but but are more convenient and aesthetically acceptable.

Question 12

Best way to decrease your intake of trans-fat.

A. Avoid take out food
B. Eat less butter
C. Eat less margarine

Answer 12

A. Avoid take out food

CPS statement trans fats what every physician to know
The largest source of trans fat is processed foods. There is widespread use of Hydrogenated oils in prepackaged foods and restaurants especially fast food restaurants.

Question 13

What indications is it appropriate to offer soy milk?
A. Vegan family
B. Fructose deficiency
C. CMPA

Answer 13

A. Vegan family

Cps recommend soy-based formula only for those who could not have dairy-based problems including cultural reasons and religious reasons and certain health issues including galactosaemia and vegan

Question 14

Obese child mom wants to know how to reduce trans fat 
A. Cut down on takeout
P. Cook with margarine
C. Don’t cook with butter
D. Choose food low in saturated fat

Answer 14

A. Cut down on takeout

Question 15

A mom wants to give her 4 month old an egg. You advise her:

A. Give the whole egg at 6 months
B. Give the whole egg at 1 year
C. Give the yolk at 6 months
D. Give the white at 6 months

Answer 15

A. Give the whole egg at 6 months

The American Academy of paediatrics issued a new guideline in 2008 that concluded there was no convincing evidence that delaying the introduction of solid foods including peanuts, eggs and fish beyond 4 to 6 months of age has a significant protective affect on allergy prevention from the CPS statement nutrition for healthy term and then 6 to 24 months.

Question 16

Infant with colic
A. Try hypoallergenic milk
B. Try soy milk
C. Give probiotic

Answer 16

A. Try hypoallergenic milk

Question 17

BMI where we would intervene for risks of obesity ?

Answer 17

A. 85%

Question 18

Autistic child, picky eater, developed gum bleeding, tender subcutaneous nodules on legs and refusing to bear weight. What is he deficient in?
A. Vitamin E
B. Vitamin C
C. Vitamin B
D. Vitamin A

Answer 18

B. Vitamin C

Ascorbic acid -Vitamin C deficiency results in the clinical manifestations of scurvy
- hemorrhage, petechiae, ecchymoses, bleeding gums, loss of teeth
-Follicular hyperkeratosis
-Hemolytic anemia
-Hypochondriasis, hysteria, depression and fatigue
-Infantile scurvy - includes irritability, pseudo-paralysis because of painful extremities,failure to thrive, and gingival hemorrhage.
- The prominence of hair follicles on the thighs and buttucks and the eruption of coiled fragmented hair with a characteristic cork
Screw appearance are specific features of vitamin C deficiency.
Petechiae found on the skin have a characteristic pale halo ring around a center you’re at the Meadows core.
Treatment is vitamin C plus supplementation for children and recommended dose is 100 mg Ascorbic acid TID for one week, then once daily for several weeks until the patient is fully recovered

Question 19

8 month old male quadriplegic, has GERd treated with ranitidine, FTT. nG places and now starting to grow. Next to consider ?

A. G-tube
B GJ tube

Answer 19

A. G-tube

Question 20

Newborn Inuit infant at 61 latitude. Recently switched from breast milk to formula, what do you prescribe ?

A. No vit D needed
B. 400 IU during winter months
C. 400 IU all the time
D. 800 IU

Answer 20

D. 800IU

The Canadian Paediatric Society advocates an increase in vitamin intake to 800 international use a day for northern Native communities during the winter months. Infant formula, dairy milk and fortified rice and soy beverages are fortified with approximately 400 international units of vitamin D, added per liter. These should be adequate sources of vitamin D as long as the infant drinks a sufficient quantity. However soy, rice and other vegetarian beverages are inappropriate alternatives to breast milk, formula or pasteurized whole whole cows milk in the first two years. A dose of 400 international of vitamin D from all sources recommended for Canadian children one year of age or younger in addition, Canadian children younger than two years of age living above northern latitude 55°, those with dark skin and those avoiding sunlight should be supplemented with 800IU of vitamin D in the winter months from October to April.

Question 21

What is the advantage of using the new WHO growth cats? (I don’t quite remember the precise options but it was some combination of breast-fed versus formula fed kids in first or latter six months and who do the curve s better represent)

A. Less mislabelled failure to thrive in breast-fed babies less than 6 months
B. Less mislabelled failure to thrive in breast-fed babies more than 6 months
C. Less mislabelled short stature (different wording, same idea) in babies less than six months
D. Less mislabelled short stature in babies more than six months

Or

What does the new WHO charts try to do?
A. Catch those losing weight in first 6 months
B. Catch those losing weight in second 6 months
C. Catch those losing ? BMI in first 6 months
D. Catch those losing ? BMI in second 6 months

Answer 21

B. Less mislabelled FTT in breastfed babies > 6 months
B catch those losing weight in second 6 month

Important differences between the WHO and CDC charts exist, and vary by age, growth indicator and specific centile or z-score. The biggest difference occur during the first 24 months, likely due to differences in study design and sample characteristics, such as type of feeding. Overall the WHO charts reflect a lighter and somewhat taller sample than the CDC charts. When both are applied to the same population, the WHO child growth standards will result in lower rates of underweight, wasting or thinness (except during the first six months of life) and higher rates of stunting, overweight and obesity. Prevailence rates appear more comparable when the 5th and 95th percentile on the CDC charts are compared with the 2.3rd centile and 97.7th centile on the WHO charts rather than the 5th and 95th percentiles.

Question 22

4 month old breastfed and then changed to formula and rice cereal. Then had rash (eczema) and then switched to soy formula. Still has rash. What do you suggest ?

A. Continue breastfeeding
B. Hydrolyzed formula
C. Continue with current plan
D. Stay on soy formula ( not sure if this was the 4th option )

Answer 22

A. Continue breastfeeding

• we thought maybe B is this is CMPA?

This sounds like acrodermatitis enterohepatica (zinc deficiency - ie; developed rash after BF was stopped. As such, BF would be protective and should be continued. This would not be an indication to use or continue with soy formula

Question 23

Vegan infant, about 1year old. Diet included two eggs per week, green leafy vegetables, soy milk. What are they deficient in ?

A. Vit B12
B. Nothing

Answer 23

A. Vitamin B12

Strict vegans are at risk of vitamin B 12 deficiency because this compound is only found in animal products. Supplementation or intake of fortified foods is therefore essential. Lacto-ovo- vegetarians can obtain B12 from dairy products and eggs if consumed regularly. Breastmilk of a strict vegan mother can be low in B 12 therefore their infant should be supplemented. Appropriate sources of B 12 include fortified soy milk, nut beverages and cereals appropriate for the needs of infants and children. Other sources of B 12 include yeast, fortified nut beverages, and cereals. It is recommended that at least three servings of food rich and vitamin B 12 be included in the daily diet or supplementation be provided at 5 to 10 µg per day. Infants of vegan mothers are at particular risk of this deficiency.

Question 24

Breastfed 7 month old babe of a vegan mom. Thriving. What do you supplement baby with ? (No vit D option )

A. Vitamin B12
B. Folic acid
C. Calcium
D. Iron

Answer 24

A. Vitamin B12

Question 25

Breastfed baby with rash around his orifices. Also glossitis. What is the cause ?

A. Vit C deficiency
B. Vitamin A deficiency
C. Zinc deficiency
D. Vitamin B12 deficiency

Answer 25

C. Zinc deficiency

Question 26

3 week old breastfeeding and growing well. Persistent jaundice. Baby A+, Mom O+. What is the cause ?

A. ABO incompatibility
B. Breastmilk jaundice

Answer 26

B. Breastmilk jaundice

Breastmilk jaundice has been traditionally defined as the persistence of physiologic jaundice beyond the first week of age. It typically presents after the first 3 to 5 days of life peaking within two weeks after birth and progressively declining to normal levels over 3 to 12 weeks.
Breastmilk Jaundice needs to be distinguished from breast-feeding failure which is suboptimal intake or starvation related jaundice that occurs within the first seven days of life resulting in excessive weight and fluid loss. In breastmilk jaundice infants commonly have total bilirubin levels > 86 mmol/L for several weeks after delivery.

Question 27

3 week old baby brought by mother for persistent jaundice. Mom is O+ and baby is A+. Baby is breastfeeding well and thriving. Unremarkable gestational and postnatal history. Likely cause for jaundice:

A. ABO incompatibility
B. Breastmilk jaundice
C. Sepsis
D. Hypothyroidism

Answer 27

Answer: this one is different as there is ABO incompatibility. But could still be breastmilk jaundice.

Question 28

Infant with skin breakdown around every orifice, glossitis, stomatitis, corneal changes and looks unwell. Most likely diagnosis ?

A. Zinc deficiency
B. Vitamin A deficiency
C. Vitamin C deficiency
D. Vitamin B12 deficiency

Or
3 month old baby with severe diaper dermatitis eczema, mucositis/stomatitis and some eye findings. What deficiency ?

A. Vitamin A
B. Zinc def

Answer 28

Answer A and B - zinc deficiency

Question 29

Adopted kid from Caribbean with edema, abdominal distension, yellow tinged rusty hair. What is the most likely ?

A. Kwashiorkor
B. Marasmus
C. B1 deficiency (Beriberi)
D. Zinc deficiency

Answer 29

Answer A: kwashiorkor = protein malnutrition.

Hypoalbuminemia and edema. Inadequate protein intake but enough carbs. Sparse hair - rusty, moon face 🌝 ,

Marasmus - sever protein- energy malnutrition. Emaciation with muscle wasting

Vit B1 thiamine

• wet Beri-Beri = cardiac involvement (edema, dilated cardiomyopathy)
• dry = nerve involvement (Wernicke’s encephalopathy, paresthesias, weakness, nystagmus)

Question 30

A mother who just gave birth to a newborn was taking propranolol and fluoxetine during her pregnancy. She now wishes to breastfeed the child. What would be your recommendation?
A. This is compatible with breastfeeding
B. Change the propranolol to another drug
C. Stop taking the fluoxetine

Answer 30

Answer A: this is compatible with breastfeeding

Selective serotonin reuptake inhibitor’s appear to be compatible with breast-feeding because adverse events in exposed infants are typically minimal. Postpartum, lactating patients who start treatment with an anti-depressant are often prescribed paroxetine or Sertraline because of their safety record. In addition, the amount of paroxetine and sertraline that is secreted into the breastmilk is generally low or undetectable, and may be less compared with other SSRIs.

Propranolol, metoprolol and labetalol our squeeze in small quantities in a compatible breast-feeding even compromised infants

Question 31

What is the best test to look for Vitamin D deficiency?

A. Serum Calcium
B. Serum 25-OH- Vitamin D
C. Serum 1-25-OH vitamin D
D. PTH

Answer 31

B. Serum 25-OH vitamin D

Among the various forms of vitamin D described above., the level of 25-OH vit D is the best indicator of vit D Status and stores.

Question 32

2 month old child who is currently being fed goat’s milk. What do you supplement with ?

A. Iron
B. Multivitamin
C. Folate
D. Calcium

Answer 32

C. Folate

Goats milk is deficient in folic acid and vit D. Infants fed goat’s milk may develop folate deficiency, especially if other sources of folate have not yet been introduced into the diet

Folate = folic acid

Question 33

3 y.o only gained 2kg last year.

A. Reassure
B. Consult dietician for intake
C. Malabsorption work up

Answer 33

A. Reassure

General guidelines regarding weight gain in infancy/childhood:

• Term neonates = lose up to 10% of birth weight over the first few days and regain birth weight by 10-14days
• newborns to 3 months = 30g (1oz) per day
• From 3-6months = 20g (0. 67oz) per day
• From 6-12months = 10g per day
• Triple BW by 1 year (double by 4 months)
• 2years to puberty = children gain 2kg per year

A prepubertal child whose weight velocity is < 1kg per year (<2.2lbs) should be monitored closely for progressive nutritional deficits

Height velocity reminder: rule of 6s
0-1year = 18-24cm/year
1-2year = 12-18cm/year
2-3year = 8-12cm/year
3-puberty = 5-6cm/year
Puberty = 10-12 cm/year

Question 34

Competitive sports and nutrition in pediatrics - which is true ?

A. Give high carb drinks
B. Give protein supplements
C. Provide a well balanced diet
D. Give calcium and vit D supplements
E. Change child’s diet according to the sport in which they are involved

Answer 34

C. Provide a well balanced diet

CPS statement: sport nutrition for young Athletes

• A well balanced diet containing appropriate amounts of macronutrients including protein, carbohydrates and fat and micronutrients including vitamins and minerals is essential to provide enough energy for growth and activity.
• Carbohydrates should comprise 45 to 65% of total caloric intake from 4-18 years old.
• Protein should comprise approximately 10-30% of total energy intake for 4-18years old
• although there are many vitamins and minerals required for good health, particular attention should be devoted to ensuring that athletes consume proper amounts of calcium, vitamin D and iron. - -Calcium is important for bone health, normal enzyme activity and muscle contraction. The daily recommended intake of calcium is 1000 mg per day for 4 to 8-year-olds and 1300 mg per day for 9 to 18-year-olds. Calcium is contained in a variety of foods and beverages including milk, yogurt, cheese broccoli, spinach and fortified green products.
• Vitamin D is necessary for bone health and is involved in the absorption and regulation of calcium current recommendations of 600 IU a day for 4 to 18-year-olds.

Question 35

Regarding breast milk vs cows milk

A. Same protein source
B. There is enough iron in cow’s milk for the first 6 months
C. The Ca:PO4 ratio is the same
D. More calories in breast milk
E. There is more carbohydrate in breast milk

Answer 35

E. There is more carbohydrate in breastmilk - human milk carbohydrate is comprised principally of lactose, with a small proportion consisting of oligosaccharides. There is carbs in breastmilk than formula

A. Same protein source - Protein source is different = whey:casein is 70:30 in human milk and bovine is 18:82. Whey protein is better as it’s more easily absorbed and promotes gastric emptying

B.there is enough iron in breastmilk for the first 6 months. Cow’s milk formula is fortified with iron and likely.

C. Ca:PO4 ratio - I cant find anything on the Ca:PO4 ratio but there is a lower concentration of calcium and phosphorous in breast milk but they are more bioavailable compared to formula
D. More calories in breastmilk - they are both 0.67kcal/ml unless you fortify them

Question 36

The best form of nutrition for an infant with short gut syndrome:

A. Breast milk
B. Long-term total parenteral nutrition 
C elements formula with MCT
D. Soy formula with MCT
E. Whey hydrolysate formula

Answer 36

A. Breast milk

Nutritional management a paediatric short bowel syndrome. Although at first glance
Breast milk may not be considered the enteral feeding of choice for infants with short bowel syndrome as the nutrients are intact and not hydrolyzed, the literature indicates that the use of breastmilk result in improved G.I. tolerance and reduce duration of parenteral nutrition in comparison to protein hydrolysate formulas.

Question 37

Some vitamins are stored in large amounts and there may be no bio chemical or clinical evidence of deficiency for many months. Which of the following vitamins behaves as such?

A. Thiamine
B. Vitamin C
C. Vitamin B 12
D. Riboflavin
E. Folate

Answer 37

C. Vit B12

According to Jeld and Steve the usual western diet contains 5 to 7mcg of cobalamine per day while the minimum daily requirement is listed as 6-9 Mcg per day. Total body stores of cobalamine are 2 to 5 mg therefore 2000 to 5000mcg approximately 1/2 of which are in the liver. As a result it takes years to develop vitamin B 12 deficiency after absorption of dietary B12.

Question 38

An infant is brought for assessment of eczema, FTT, diarrhea, and a rash around his mouth and anus. What is the likely deficiency:

A. Vitamin A
B. Zinc
C. Copper
D. Niacin
E.riboflavin

Answer 38

Answer B. Zinc

Question 39

A 13 month old child on a vegetarian diet is at risk for which deficiency:

A. Vit C
B. Calcium
C. Folate
D. Zinc
E. Iron

Answer 39

E. Iron

Question 40

Child with short gut. Which is the best form of feeding ?

A. Elemental formula with MCT
B .soy formula with MCT
C. TPN
D. Lactose free formula
E. Gluten free diet

Answer 40

A. Elemental formula with MCT - apparently - does anyone have a resource for this ? Other question had breastmilk which seems to be best

Question 41

Which of the following is true regarding iron supplementation in a preterm infant who is breastfed:

A. Do not use iron as it interferes with absorption of iron in breastmilk
B. Start iron supplementation at 1 month of age
C. Start only if on a non-iron fortified supplemental formula

Answer 41

B. Start iron supplementation at 1 month of age

CPS - iron deficiency Anemia in children

Preterm infants fed human milk should receive an iron supplement of 2mg/kg/day by one month of age until weaned to iron-fortified formula or beginning complementary foods

Question 42

Kid drinking unpasteurized milk from farm.

A. What is she deficient in ?
B. What are 3 bacteria that can be found in unpasteurized milk ?

Answer 42

A. Vit D deficiency
B. 3 bacteria
- salmonella 
- listeria
- E.coli

Question 43

6 month old baby with severe diaper dermatitis and bluish crusted lesions, resistant time routine treatment for candida for 6 months (not sure of duration) . Noted to have petechiae and brownish lesions at periphery.

A. What are 3 ddx?
B. What’s the most important test to order ?

Answer 43

A. 3 DDX

1. Zinc deficiency
2. Langerhans cell histiocytosis
3. Seborrheic dermatitis
4. Atopic dermatitis
5. Scabies
6. Immunodeficiencies
7. Biotin deficiency

B. Most important test?

Zinc level vs skin biopsy

Question 44

Anemia with Ferritin of 5. Determine to be nutritional.

A. What are 2 nutritional pieces of advice to give ?
B. What is the appropriate treatment?
C. How long should the treatment be provided?
D. When should the patient be brought back for follow up ?

Answer 44

A. 2 nutritional pieces of advice

1. Limit cow’s milk consumption to mor more than 16oz (600ml) per day.
2. Encourage at least 3 servings per day of iron containing foods ie; fortified breakfast cereal, 3oz of meat, or 4 oz of tofu; children who eat less than this target usually have suboptimal iron intake and may benefit from an iron supplement

B. What is the appropriate treatment ?
- iron supplementation 3-6mg/kg/day (standard recommended dosing is 3-6mg/kg elemental iron per day. Ferrous sulfate and 3mg/kg is effective

C. How long should to be provided ?
- until you can correct Hb and HT + 2-3 months additional treatment for iron stores

D. When should the patient be brought back for follow-up ?
If severe 1-2 weeks after, if mild 4 weeks after

AAP
Expected retic response = 7-10days
Check Hb in 1 month to ensure response and compliance
Duration of tx until you can correct Hb and HT + 2-3months additional tx for iron stores

Indication for referral

1. If no response in 4-8weeks
2. Recurrence of anemia
   - GI loss
   - iron malabsorption
   - non-compliance
   - other: thalassemia, lead poisening
   - rheumatic/chronic infections - low serum iron, and low TIBC and high ferritin

Question 45

Please match the following case scenarios with the appropriate nutritional supplements ?

A. 4 month old male with a chylothorax
B. 2y.o old neurodevlopmentally delayed child with G-tube
C. 3 month old male with confirmed eosinophilic esophagitis
D. Neonate norm to a HIV positive mother on antiretrovirals, both of whom live in rural sun- Saharan Africa

Options

1. Pediatric formula 1.0kcal/ml
2. Breast feed ad lib
3. Hydrolyzed protein formula
4. Elemental formula with 0% fat

Answer 45

A. 4 month old male with chylothorax = elemental formula with 0% fat
B. 2 year old neurodevelopmentally delayed child with a G-tube = pediatric formula
C. 3 month old male with confirmed eosinophilic enteritis = hydrolyzed protein formula
D. Neonate born to an HIV positive mother on antiretrovirals, both of who live in rural sun-Saharan Africa = breast feed ad lib

Question 46

Young girl with CP who is in a wheelchair with contractures. Other than weight, what are three anthropometric measures of nutrition that can be used ?

Answer 46

3 measures of nutrition

1. Tricep skin fold
2. Subscapular skin fold
3. Lower leg length or arm length

In children with skeletal deformities such as scoliosis or contractures, alternative measures such as lower leg length or upper arm length, may be obtained. Triceps skin fold thickness and mid- arm circumference are often helpful in assessing nutritional status and may even be more accurate than weight- for- height to detect malnutrition. Subscapular skinfold is often less affected than triceps skinfold in malnourished neurologically impaired children.

Question 47

Presented with growth curves. Child with severe spastic CP presents with height 3rd percentile and weight below the 3rd%. He has intermittent choking with feeds. There’s no vomiting or diarrhea. They are not on any medications and are otherwise healthy. What are five things you want to do for management.

Answer 47

1. Consult occupational therapy
2. Feeding study
3. Thicken feeds
4. Trial of PPI
5. Consider NG or G-tube

Nutrition of neurologically impaired children article

Question 48

Kid with celiac disease, taking megavitamins, has pseudo tumor cerebri. What is the cause ?

Answer 48

Vitamin A toxicity

The only well-established human vitamin neurotoxic effects are those due to hypervitaminosis A (pseudotumor cerebri) and pyridoxine (sensory neuropathy). In each case the neurological effects of vit def and vit excess are similar. Closely related to the neurological symptoms of hypervitaminosis A are symptoms including headache, pseudotumor cerebri, and embryotoxic effects reported in patients given vit A analogs or retinoids.

Question 49

Vegan kid.

A. Deficient in ?
B. What is the worse complication of vitamin B12?

Answer 49

A. Vitamin B12 ( also in VitD, calcium, iron, zinc)

B. Worse complication - irreversible cognitive defects

And under nourished children subclinical vitamin B 12 deficiency contributes to poor linear growth and weight gain. Overt deficiency may cause megaloblastic anemia, atrophic glossitis, neuropathy, and demyelination of the central nervous system. Infants may present with nonspecific symptoms including weakness, failure to thrive, developmental delay, afebrile seizures, involuntary movements, nystagmus, tremors, and irritability. If untreated, irreversible cognitive deficits may occur.

Question 50

Kwashiorkor kid

A. Gets rash with sun exposure, what is he deficient in ?
B . Name 3 things you would do to make sure he gets refer safely ?

Answer 50

A. Not sure what they are looking for here; it’s either protein/fat deficiency or Niacin B3 deficiency as in Pellegra. In kwashiorkor, typically children do not present with photodermatitis, this is more characteristic of pellagra

B. Management of severe malnutrition - 3 things

1. Treat hypoglycemia, hypothermia, or infection if present
2. Treat dehydration if present -PO/NG rehydration when possible using ORS (ReSoMal - contains less sodium and more potassium); IV fluids only if severe hypovolemia or shock due to risk of over hydration and heart failure. Volume of 70-100ml/kg body weight of ReSoMal usually is enough to restore normal hydration; should be given over 12h
3. Slow/cautious refeeding
4. Monitor and treat electrolyte abnormalities
5. Start dietary supplementation - particularly Vit A, iron, folate

Question 51

Name a medical condition that is a contraindication (in a baby) to breastfeeding ?

Answer 51

Galactosemia

Question 52

An 11-month-old baby girl presents with a history of diarrhoea and failure to thrive. She also has developed the rash shown in the figures. The symptoms started shortly after switching from breastmilk to formula. Please identify the diagnosis to explain the symptoms.

Answer 52

Zinc deficiency - acrodermatitis enterohepatica

Typically occurs when diet is changed from breastmilk to formula or solids because Zinc is more easily absorbed from Breast milk.

Question 53

TPN - list 4 metabolic complications

Answer 53

1. Electrolyte abnormalities
2. TPN cholestasis
3. Hypertriglyceridemia/hyperlipidemia
4. Metabolic bone disease
5. Hyper/hypoglycemia

Question 54

4 effects of excess Vitamin D

Answer 54

Symptoms of acute intoxication are due to hypercalcemia and include

1. Confusion
2. Polyuria and polydipsia
3. Anorexia and vomiting
4. Muscle weakness

Chronic intoxication may cause:

1. Nephrocalcinosis
2. Bone demineralization
3. Pain

Stones, groans (abdo pain), bones (bone pain) and psychiatric overtones (confusion)

Question 55

A 13 year old girl comes to you with a BMI of 24 (have to plot….plots play 90%)

A. Interpret the BMI
B. What is considered a healthy BMI ?

Answer 55

A. Overweight BMI 85-95%

B. Healthy BMI is 3-85%ile

Question 56

After a recent Listeriosis scare, a family decides to change to a vegetarian diet. They are at risk of what nutrient deficiency ?

Answer 56

Iron

Vegans and lacto-OCP-vegetarians require 1.8 times the iron intake of nonvegitarians because of different bioavailability

Question 57

An ex-28 weeker is now 9weeks old and is ready for discharge. Does he need iron supplementation. Explain your answer.

Answer 57

Yes he does.

The AAP recommends iron supplementstionof at least 2-4mg/kg/day for all preterm infants after enteral feeding is established and should continue at least 2mg/kg/day of iron (through supplements or fortified formula) for the first year of life

If the baby is breastfed - start iron supplement of 2mg/kg/day at 4 weeks and continue through the first year. This can be provided as medicinal iron or iron-fortified complementary foods.

If formula fed - iron fortified formula or complementary from the start to 1 year.

Question 58

Mom asks you to prevent poor dentition in her soon-to-be born child. Name 3 suggestions you would give her

Answer 58

1. Wipe your baby’s gums with a soft, clean, damp cloth twice a day
2. As soon as the first teeth appear, clean them at least once a day (usually at bedtime) with a soft bristle toothbrush designed for babies. Lay your baby on a flat surface or with head cradled in Your lap to brush teeth
3. Avoid leaving your baby in bed with a bottle
4. After 6 months, introduce a soppy cup. Avoid juice and offer water instead.
5. If you breastfeed before nap time be sure to to clean your child’s teeth before he goes to sleep.
6. Never sweeten a soother
7. Don’t put a soother or bottle nipple in your own mouth for any reason. Bacteria, viruses and yeast can be passed to your child this way
8. Have a dental home by 12 months

Question 59

A. What is the criteria for a child to be called obese ?

B. What is the criteria for a child to be called overweight ?

Answer 59

A. Obese >95%ile

B. Overweight 85-95%ile

Check to see if this has changed ?

Question 60

Child with BMI over 31.

A. How do you calculate BMI (give formula )
B. What are 5 diseases that he is at risk for ?

Answer 60

A. BMI = weight in kg/height in meters
^2

B. Obesity 
Resp
- sleep apnea
- snoring
- pickwickian syndrome
-asthma

Orthopedic

• Blount disease
• slipped capital femoral epiphysis

GI

• gallbladder disease
• steatohepatitis

Cardio

• dyslipidemia
• HTN

Endo

• insulin resistance
• hyperinsulinism
• Impaired glucose tolerance
• type 2 diabetes
• PCOS
• menstrual irregularity

Psychological

• depression
• eating disorders
• social isolation

Question 61

A mother comes In with her newborn baby and tells you that she lives out in the country where they have well water. What should she do about vitamins and fluoride? What do you tell her about each and be specific.

Answer 61

A. Vitamins and fluoride?

• Give vitamin D 400 international units and start today
• Fluoride = give none now and wait until six months once teeth have erupted

CPS statement on vitamin D supplementation: supplement infants with 400 international units of vitamin D daily unless living in the north and it’s winter in which case give 800 international units.

CPS statement fluoride use;
Supplemental fluoride should be administered only from the age of six months, and only if the following conditions prevail:
- Concentration of fluoride in drinking water is less than 0.3ppm
- child does not brush his/her teeth (or have them brushed by parent guardian) at least twice a day
- If in the judgement of a dentist or other health professional, the child is susceptible to high caries activity such as family history, caries trends and patterns in communities or geographic areas.

Because the action of fluoride is topical, no fluoride should be given before teeth have erupted. Supplemental fluoride should be given in preparations that maximize the topical effect such as mouthwashes or lozenges. Drops if used should be diluted with water and and squirted on teeth.