Paediatrics: Nutrition

Question 1

What are the clinical features of Rickets

Answer 1

1. FTT or poor growth
2. Bone pain + fractures
3. Muscular weakness
4. Bone deformity - wrist swelling, costo-chondral junction swelling, bowing of long bones, frontal bossing, craniotobes (softening of skull, with ping pong sensation on pressing)

Question 2

How can you tell the difference between vitamin d dependent rickets type 1 and type 2

Answer 2

(A) Type 1 - renal 1a-hydroxylase deficient

• severe Rickets presentation in 1st 24months of life
• Low 1, 25 OHD

(B) Type 2 - Vitamin D receptor gene mutation

• sparse hair or total alopecia in first 12 months
• High 1, 25 OHD

Question 3

What is the treatment of Rickets?

Answer 3

Calcitrol (1, 25 dihydroxyvitamin D3 i.e. vitamin D replacement)

Question 4

What are the key causes for Rickets world wide?

Answer 4

Malnutrition and Dietary insufficiency

Question 5

What are the genetic causes of Rickets?

Answer 5

VDDR type 1 - renal 1A-hydroxylase def.
VDDR type 2 - vitamin D receptor def.
Both are autosomal recessive

Question 6

What are the growth assessment for a ?malnourished child?

Answer 6

1. Detailed food diary (5-7d)
2. BMI
3. Serial height and weight
   - Fall of 2 centiles or more or below 3rd centile = impairment
4. % weight of height (current weight/expected weight for high centile x 100)
   - if ≤ 90% impairment
5. mid arm circumference / Head circumference
   - if <0.31 impairment
6. Bloods - Albumin (likely low), FBC, TTG, U+Es, Ca2+, Mg2+, PO4,

Question 7

What are the similarities and differences between kwashiorkor and marasmus disease?

Answer 7

Both are severe deficiency in Protein

Kwashiorkor (protein and AA):

1. Growth retardation
2. Oedema
3. Depigmentation of skin and hair
4. Liver disease (fatty liver)
5. Diarrhoea and abdominal distension
6. Apathy
   - Low Ca2+, Mg2+, PO4 and hypoalbuminaemia

Marasmus (nutrition and protein):

1. Height relatively normal compared to weight
2. Wasted appearance
3. Muscular atrophy
4. Listless
5. Diarrhoea ± constipation
   - Low serum albumin

Question 8

What is the treatment for malnutrition?

Answer 8

1. Correct hydration, electrolytes, glucose, minerals etc.
2. Refer to dietician
3. Food first approach (aim to increase dietary intake)
4. ONS (ensure - give after or before meals, must not be replacement)

Question 9

What is the NICE definition of malnutrition?

Answer 9

BMI of <18.5 or
Unintentional weight loss > 10% over 3-6 months or
BMI <20 and unintentional weight loss >5% over 3-6 months