Nutrition

Question 1

Why are solid foods typically introduced at 6 months of age in an infant’s diet?

Answer 1

Necessary Motor Skills for Complementary Feeding are Present; Renal and GI Tracts are Almost Fully Mature

By 6 months of age, most infants have the ability to chew food and control their head and trunk. In addition, infants at this age can absorb most nutrients and regulate elimination. Earlier introduction of solid foods is discouraged because it is associated with increased levels of obesity.

Question 2

Which vitamin is necessary for maintaining prothrombin, Factor 7, Factor 9, and Factor 10?

Answer 2

Vitamin K

Vitamin K deficiency is most common in children with conditions that cause malabsorption of fat-soluble vitamins (cystic fibrosis, ulcerative colitis, history of intestinal resection), or in newborns and infants who haven’t developed significant bacterial gastrointestinal flora.

Question 3

What are some examples of indications for parenteral nutrition?

Answer 3

Short Bowel Syndrome, Inflammatory Bowel Disease, Critical Illnesses Preventing Use of the Intestine

Other examples include bowel obstruction and high-output fistulas. Parenteral nutrition is needed when the patient’s GI tract cannot adequately support normal growth and development. With parenteral nutrition, nutrients are delivered directly into the venous circulation and forego the first-pass effect through the liver. Total parenteral nutrition (TPN) is used to supply all of the body’s nutritional needs and partial parenteral nutrition (PPN) is used to supply a portion of the body’s nutritional requirements.

Question 4

A 10-year-old boy who lives in the Northern Hemisphere develops bowed legs and fractures easily.

What condition does he likely have and what is the treatment?

Answer 4

Rickets; Vitamin D Supplementation

In children, rickets from vitamin D deficiency causes poor bone mineralization, leading to weak bones. Children with limited sun exposure or those with conditions that inhibit absorption of vitamin D (e.g., cholestasis, inflammatory bowel disease, cystic fibrosis, short bowel syndrome) need supplementation. Treatment is with vitamin D supplementation to correct levels to normal. For infants ≤ 12 months of age, treat with 2,000 IU/day for 90 days. Children 1–12 years of age should receive 3,000–6,000 IU/day for 90 days. Treat children > 12 years of age with 6,000 IU/day for 90 days. Follow-up is required to monitor 25-OH vitamin D, calcium, and phosphorus levels. Obese children and those with malabsorptive syndromes may require higher doses to reach 25-OH vitamin D levels of > 30 ng/mL.

Question 5

What vitamin functions as a membrane-bound antioxidant by inhibiting free radical–catalyzed lipid peroxidation and terminating radical chain reactions?

Answer 5

Vitamin E

Vitamin E serves to protect the body from biologic processes that damage cellular and intercellular structures. Deficiency can result in neurologic dysfunction and loss of reflexes.

Question 6

A family is on a strict vegan diet.

What possible vitamin and mineral deficiencies might they have?

Answer 6

Vitamin B₁₂, Iron, Calcium, and Zinc

Vegetarianism and veganism are acceptable diets for children and other groups as long as appropriate supplements are included (for strict vegans: vitamin B₁₂, iron, calcium, and zinc). Groups especially at risk are infants, children, and pregnant and lactating women. Risks are minimal with a semivegetarian diet, such as one that includes eggs, milk, and/or nonred meat in the nutritional regimen.

Question 7

• Paraesthesias
• Foot and wrist drop
• Ophthalmoplegia
• Ataxia
• Confusion

What deficiency is associated with these findings?

Answer 7

Thiamin (B₁) Deficiency

B₁ deficiency is associated with beriberi, which presents with paraesthesias, foot drop, and wrist drop. Also know that B₁ deficiency is responsible for Wernicke encephalopathy, with its triad of ophthalmoplegia, ataxia, and confusion.

Question 8

In a child, what is severe calorie malnutrition without edema called?

Answer 8

Marasmus

Children with marasmus have generalized loss of muscle and no subcutaneous fat. The term marasmus is being phased out by some and replaced with the term protein-energy malnutrition without edema.

Question 9

Compared to infant formula, human milk is deficient in which fat-soluble vitamin?

Answer 9

Vitamin D

Breastfed infants need supplementation with 400 IU of vitamin D per day. Vitamin D–fortified cow’s milk formula contains adequate vitamin D, provided the infant consumes at least 1,000 mL per day. Human milk mineral levels (e.g., calcium, magnesium, phosphorus, iron, copper, and zinc) are lower but are more bioavailable than cow’s milk–based formulas. Other important beneficial substances are found only in human milk (e.g., amylase, lipase, growth factors, and immunoprotective proteins [e.g., immunoglobulins, lactoferrin, lysozymes, and cytokines]).

Question 10

When can complementary feeding start in infancy? What is the sequence of solid food introduction?

Answer 10

6 Months of Age; Iron-Fortified Cereals, Then Strained or Pureed Fruits and Vegetables, Then Meats and Poultry

Complementary foods may be introduced as early as 6 months of age. Earlier introduction of solid foods is discouraged because it is associated with increased levels of obesity. By 6 months of age, most infants have the necessary motor skills for complementary feeding (e.g., ability to chew food, appropriate head and truncal control). The infant’s renal and GI tracts are also considered almost fully mature at this time (able to absorb most nutrients and regulate elimination). In the U.S., the following sequence of foods is usually started: iron-fortified cereals, then vegetables and fruits that are strained or pureed, then meats and poultry.

Question 11

An infant who is given goat’s milk is most likely to be deficient in which vitamin?

Answer 11

Folate

Goat’s milk does not contain adequate folate. Therefore, folate deficiency is common in children who are fed a diet of goat’s milk. Folate deficiency is a primary cause of hematological problems, including leukocyte and cellular immune dysfunction. It is the #2 nutritional cause of anemia.

Question 12

A 12-year-old boy whose diet is composed mostly of meat experiences gingival bleeding while brushing his teeth. He also notices that he bruises easily. He is tired most of the time and has noticed changes in his hair consistency. Last month, he fractured his wrist when he fell on the floor and hurt his hand.

What vitamin could he be deficient in?

Answer 12

Vitamin C

Vitamin C (ascorbic acid) deficiency is known as scurvy. Symptoms of vitamin C deficiency include gingival bleeding, follicular hyperkeratosis and “corkscrew-coiled” hairs. Normochromic, normocytic anemia is also common, as well as brittle bones that fracture easily. Treatment is with vitamin C supplementation and vitamin C–rich fruits and vegetables such as strawberries, tomatoes, citrus fruits, potatoes, spinach, broccoli, cauliflower, and Brussels sprouts.

Question 13

Breastfeeding is contraindicated if the mother is taking what classes of drugs?

Answer 13

Amphetamines, Chemotherapy Agents, Ergotamines, Statins

In general, it is recommended that mothers who take drugs from these classes not breastfeed. In addition, technetium-99m is excreted in breast milk and requires temporary cessation of breastfeeding until the isotope is completely excreted.

Question 14

• Dermatitis
• Dementia
• Diarrhea

What deficiency is associated with these 3 findings?

Answer 14

Niacin (B₃) Deficiency

Niacin deficiency is associated with pellagra. Remember the 3 Ds of pellagra: dermatitis, dementia, and diarrhea. Pellagra is most commonly seen in areas where people get most of their calories from maize (e.g., rural South America).

Question 15

What type of infant formula is recommended for infants with galactosemia?

Answer 15

Soy-Based Formula

Galactosemia is an autosomal recessive metabolic disorder where the enzyme galactose 1-phosphate uridyl-transferase (GALT) is deficient. GALT plays an important role in the metabolism of galactose. Lactose, the main carbohydrate found in cow’s milk–based formulas and also in breastmilk, is composed of glucose and galactose. Inability to metabolize galactose affects many organ systems and is responsible for the manifestations of galactosemia. Soy protein is the main source of protein in soy-based formulas, so they are recommended for infants with galactosemia. Another option is hypoallergenic formulas, where the protein component is modified into partially digested protein hydrolysates or amino acids components.

Question 16

What supplements should be given to exclusively breastfed babies?

Answer 16

Vitamin D and Iron

Vitamin D supplements (400 IU/day) should begin in all exclusively breastfed infants in the first few days of life and continue until the infant is weaned from breastfeeding and is consuming at least 1,000 mL (33 oz) a day of vitamin D–fortified formula or milk. Full-term, healthy, breastfed babies should receive daily supplementation with 1 mg/kg of elemental iron starting at 4–6 months of age, continuing until iron-rich complementary foods are introduced (i.e., cereal). No additional supplementation is recommended in infants fed iron-fortified formula. Whole or 2% cow’s milk should not be started until after 12 months of age.

Question 17

• Cheilosis
• Sore tongue

What deficiency is associated with these 2 findings?

Answer 17

Riboflavin (B₂) Deficiency

Cheilosis (a.k.a. stomatitis) is a condition in which the lips, particularly at the corners of the mouth, become cracked and inflamed. This condition, and the accompanying sore tongue, is associated with B₂ deficiency. This deficiency can also interfere with iron absorption, leading to normochromic normocytic anemia.

Question 18

What disorder is seen in children with insufficient intake of protein resulting in edema?

Answer 18

Kwashiorkor

Kwashiorkor is due to insufficient intake of protein. Kwashiorkor is an African term that means “the disease of the deposed baby when the next one is born.” And, as expected, it appears in young children during the weaning or postweaning process. The term kwashiorkor is being phased out by some and replaced with protein-energy malnutrition with edema.

Question 19

When can an infant be started on cow’s milk?

Answer 19

12 Months of Age

Cow’s milk contains forms of iron that have decreased bioavailability to humans. In addition, its iron content is low—inadequate for a growing infant or child. It also has higher levels of protein and minerals that may inappropriately increase the solute load on the infant’s kidneys.

Question 20

A 1-year-old presents with:

• Irritability
• Anorexia
• Follicular hyperkeratosis
• “Corkscrew-coiled” hairs
• Gingival bleeding
• Normochromic, normocytic anemia

What is the most likely diagnosis?

Answer 20

Vitamin C Deficiency (Scurvy)

Vitamin C, or ascorbic acid, deficiency is rare in the U.S. Most cases occur between 6 months and 2 years of age. Vitamin C deficiency impairs the formation of collagen (results in fragile capillaries and gingival hemorrhage) and chondroitin sulfate (results in brittle and easily fracturing bones).

Question 21

At what age can infants be transitioned to cow’s milk?

Answer 21

12 Months of Age

Before 12 months of age, infants should only get their milk product as breast milk (preferred) or iron-fortified formula. Because infants need fat for brain development, offer whole milk to most 12- to 24-month-old toddlers. At the same age, offer pasteurized 2% milk to weaned infants who are at risk of obesity or have a family history of high cholesterol, obesity, or heart disease. All children should be on skim or 1% pasteurized milk by 2 years of age.

Question 22

Name the 4 fat-soluble vitamins.

Answer 22

Vitamins A, D, E, and K

Vitamins A, D, E, and K are the fat-soluble vitamins and require carrier proteins for transport. They all require intact mechanisms for fat digestion and absorption for uptake. These vitamins are responsible for regulating protein synthesis.

Question 23

Using the Holliday-Segar equation, what is the daily caloric requirement (kcal per day) for a 20-kg child?

Answer 23

1,500 kcal per Day

The Holliday-Segar equation for calculating daily caloric requirements (kcal per day) under basal conditions is:
(100 kcal/kg for the first 10 kg) + (50 kcal/kg for the next 10 kg) + (20 kcal/kg for the rest of the weight)

For a 20-kg patient, the total kcal required per day is:
(100 × 10) + (50 × 10) or 1,000 + 500 = 1,500 kcal per day.

Question 24

At what age should a cup first be introduced?

Answer 24

6–9 Months of Age

It is best to first introduce a cup at 6–9 months of age, with the goal of weaning from a bottle at no later than 12–15 months of age.

Question 25

What is a common cause of sore nipples during breastfeeding?

Answer 25

Poor Latching Position

Other common breastfeeding problems and what to do about them:

1. Poor maternal “let down.” This can be caused by inadequate fluid intake, fatigue, stress, and medications.
2. Early introduction of formula feeding. Encourage mothers who are considering bottle-feeding to hold off for at least several weeks to allow lactation to begin and persist.
3. Too-rigid schedules for breastfeeding. Breastfeeding every 2–3 hours, 10–15 mins per breast is generally sufficient for most infants.
4. Lack of lactation support. Refer to a lactation support group and provide assistance with lactation services.

Question 26

How often do healthy formula-fed newborns feed and how much do they eat?

Answer 26

2–3 Ounces Every 2–3 Hours

There is no hard and fast rule to feeding. In general, newborns may be fed 2–3 ounces every 2–3 hours. At around 2–3 months of age, the feeding volume may increase to 4–5 ounces every 3–4 hours; at 4–5 months of age, 4–6 ounces every 4–5 hours; at around 6 months of age, 6 ounces every 4–5 hours, with the addition of complementary foods. At 6 months of age, formula should be ≤ 30 ounces per day and should be < 65% of daily calories.

Question 27

• Night blindness
• Bitot spots (keratinization of the cornea)
• Xerophthalmia (dry eyes)
• Corneal opacities
• Growth failure
• Increased susceptibility to infection

Deficiency of which vitamin results from these findings?

Answer 27

Vitamin A (AKA Retinol)

Vitamin A deficiency can produce any of these findings. Know that children with vitamin A deficiency also are at higher risk for severe measles.

Question 28

A 13-year-old boy with mild acute pancreatitis continues to have abdominal pain and has not been eating for 5 days.

What is the next step in providing nutrition support?

Answer 28

Start Enteral Feedings (Either Gastric or Jejunal)

Enteral feedings (tube feedings) are used in patients who cannot ingest enough calories/nutrients by mouth but have a functional GI tract. Enteral feedings are used in dysphagia, neurological disorders, prematurity, sepsis, cancer, short bowel syndrome, and cystic fibrosis. Whenever possible, this route should be used to meet some of the patient’s nutritional needs and to keep the gut functioning. For short-term use of ≤ 1 month, use a nasogastric or nasojejunal tube to deliver liquid nutrition directly to the stomach or small intestine, respectively. For longer use, a gastrostomy or jejunostomy is performed.

Question 29

When should breastfed preterm infants start iron supplementation?

Answer 29

1 Month of Age

Beginning at 1 month of age and continuing until 12 months of age, breastfed preterm infants and those with low birth weight need 2 mg/kg of iron per day. Formula-fed preterm infants may benefit from an additional 1 mg/kg/day of iron supplementation. Cow’s milk should not be introduced earlier than 12 months of age. It contains forms of iron that have lower bioavailability to humans. In addition, cow’s milk has low iron content and may not adequately meet iron requirements of the growing infant or child.

Question 30

Rickets is due to what vitamin deficiency? What are the manifestations of rickets?

Answer 30

Vitamin D; Weak Bones, Bone and Dental Deformities, Short Stature, Muscle Weakness

In children, vitamin D deficiency causes poor bone mineralization, leading to weak bones. In adults, vitamin D deficiency results in osteoporosis or osteomalacia. Children with limited sun exposure or those with conditions that inhibit absorption of vitamin D (e.g., cholestasis, inflammatory bowel disease, cystic fibrosis, short bowel syndrome) need supplementation. Signs and symptoms of rickets include bone pain, bone deformities (e.g., bowlegging, “pigeon chest,” “rachitic rosary,” asymmetrical or odd-shaped skull and craniotabes), increased tendency to fracture, short stature, dental problems, and muscle weakness. Most infants and children, however, are asymptomatic and are diagnosed from an incidental finding on physical examination.