Pediatric Module

Question 1

Question: 1 

Which of the following children is at greatest risk for iron deficiency anemia?

1: 4 month-old term infant exclusively fed human milk

2: 4 month corrected gestational age, former preemie on a transitional formula

3: 10 month-old switched from formula to whole milk

4: 17 month-old “picky eater”

Answer 1

3: 10 month-old switched from formula to whole milk
Iron deficiency anemia is the most common nutritional deficiency in childhood. While human milk is low in iron content, it is very efficiently absorbed. Infants exclusively fed human milk require an iron supplement starting at 4-6 months of age. Transitional infant formulas are fortified with sufficient iron to meet the needs of infants with a history of prematurity. The iron content of cow’s milk is inadequate and not efficiently absorbed by infants. Cow’s milk should not be introduced before 12 months of age. To avoid iron deficiency anemia, children should avoid excessive milk intake, which can displace the intake of food items with greater iron content.

Question 2

Question: 2 

A morbidly obese 12 year old female is admitted to the hospital for an evaluation of sleep apnea. A diet history reveals that she drinks three - 10 ounces cans of soda, 24 ounces of juice, and 8 ounces of chocolate milk daily. In what mineral may she be deficient?

1: Calcium

2: Phosphorus

3: Selenium

4: Potassium

Answer 2

1: Calcium

Increased fruit juice and soft drink consumption in children has been a public health focus. Studies in the past have indicated that increased intake of juices, sodas, and sweetened beverages have placed children at higher risk for deficiencies in minerals such as Magnesium and Calcium. This is due to the corresponding decrease in consumption of beverages like milk that promote bone health. Increased consumption of these caloric beverages has also been associated with obesity risk in this population. A more recent study suggests that caloric beverages (milk, juice, sweetened beverages) consumed by children were complementary to each other , and that more of a focus needs to be on total caloric intake for weight management, and promoting balanced nutrient intake. Other recent findings claim that over consumption of juice in particular is not necessarily associated with decreased intake of milk, and other food groups. It remains important to adhere to age appropriate recommendations for such beverages to ensure that proper nutrition is practiced. The American Academy of Pediatrics (AAP) suggests 4 to 6 ounces of 100% juice per day in children one to six years of age, and up to 12 ounces per day in children ages seven to eighteen years old. The AAP also states that drinking three 8-oz glasses of milk per day (or equivalent in other non-dairy sources) will achieve the recommended adequate intake of calcium in children 4-8 years of age and four 8-10 ounce glasses of milk (or equivalent) will provide the adequate calcium intake for adolescents.

Question 3

Question: 3 

A child with cerebral palsy and a gastric feeding tube is admitted to the hospital for a fundoplication. This procedure is used to treat

1: gastroesophageal reflux.

2: oral/motor dysfunction.

3: malnutrition.

4: esophagitis.

Answer 3

1: gastroesophageal reflux.
Neurologically impaired children are at risk for aspiration and pneumonia from severe gastroesophageal reflux. Medical therapy for these children is not very effective. The most common surgical techniques used in the treatment of severe reflux in the United States are the Thal and Nissen fundoplications which are performed via open or laporoscopic approach. Vigorous trials of aggressive medical therapy including anti-reflux medication, proton pump inhibitors, dietary adjustments and positioning should be tried before a child undergoes an anti-reflux procedure.

Question 4

Question: 4 

The chronic use of steroids in premature infants has been associated with

1: osteopenia.

2: cholestasis.

3: nephrolithiasis.

4: hypoglycemia.

Answer 4

1: osteopenia.

Dexamethasone is a potent steroid used to assist with ventilator weaning of premature infants. Chronic steroid use can have a negative impact on nutritional status. Steroids interfere with calcium and vitamin D metabolism, increase protein catabolism, alter bone formation and resorption, and interfere with the growth hormone-insulin-like growth factor axis, all of which could lead to osteopenia.

Question 5

Question: 5 

When used in assessment of critically ill children, how do predictive equations compare to indirect calorimetry?

1: No consistent comparison can be found

2: Equations typically overestimate needs

3: Equations typically underestimate needs

4: Equations correlate well with indirect calorimetry


Answer 5

1: No consistent comparison can be found

Many methods of predicting energy expenditure in children are available. However, when compared with actual measurements using indirect calorimetry, most equations are significantly different (both overestimating and underestimating.)

Question 6

Question: 6 

A 13-year-old boy whose body mass index (BMI) is at the 97th percentile on the Centers for Disease Control and Prevention growth chart for age and sex would be classified as

1: underweight.

2: healthy weight.

3: overweight.

4: obese.

Answer 6

4: obese.
BMI is a screening tool used to identify children over 2 years of age and adolescents who are outside of their healthy weight ranges. Children with age and sex specific BMIs between the 85th and 94th percentiles are classified as overweight and those with BMIs greater than or equal to 95th percentile are classified as obese.

Question 7

Question: 7 

Which of the following is NOT associated with a delayed bone age in a child with short stature?

1: Hypothyroidism

2: Precocious puberty

3: Cushing syndrome

4: Growth hormone deficiency

Answer 7

2: Precocious puberty

One of the most useful diagnostic tests in assessing a child with abnormal growth is a “bone age”. The bone age is evaluated by a radiography of the patient’s knees or left wrist. Using established norms for different ages and sexes, a trained observer can estimate the degree of maturation of the bones. Precocious puberty is usually associated with an advanced bone age, while children with genetic short stature typically have a bone age similar to their chronological age. Hypothyroidism, growth hormone deficiency and Cushing syndrome all are associated with a delayed bone age.

Question 8

Question: 8

Which of the following preterm growth charts allows for comparison for preterm infants from 22 weeks gestational age up through 10 weeks post term age?

1: Fenton

2: Ehrenkranz

3: Dancis

4: Lubchenco

Answer 8

1: Fenton
The Fenton growth chart, updated from data previously collected by Babson and Benda, has many benefits over other available growth charts. Data was collected from a large sample size and validation of the chart occurred by using data from the National Institute of Child Health and Human Neonatal Research Network; CDC growth charts; intrauterine growth data, and postnatal growth data. The data is cross sectional and is best used to assess growth over time. A major advantage is that it allows for tracking of growth from 22 weeks gestational age up through 10 weeks post term age.

Question 9

Question: 9 

How often does the American Academy of Pediatrics recommend screening for iron deficiency anemia?

1: Once between the age of 9 and 12 months for all infants

2: Once between the ages of 2 and 6 years in all children

3: Once a year in all adolescents

4: Yearly if a child drinks >24 ounces of milk per day

Answer 9

1: Once between the age of 9 and 12 months for all infants

Iron deficiency anemia is important to identify in young infants and children because of its adverse effects on behavior and development. The American Academy of Pediatrics offers two options for screening. Universal screening, or measurement of hemoglobin or hematocrit for all full term infants between 9 and 12 months, is one option. An alternative option is Selective Screening, or screening only infants deemed to be at risk such as preterm infants, infants not receiving iron fortified formula, and infants fed human milk who are older than 6 months who are not consuming an iron rich diet. Selective screening may be a better option for communities with a historically low incidence of anemia and where there are generally good infant dietary practices related to iron nutrition.

Question 10

Question: 10 

Using the Waterlow criteria, weight for length is evaluated as an index of which of the following?

1: Wasting due to acute malnutrition

2: Wasting due to chronic malnutrition

3: Wasting caused by illness

4: Wasting caused by hypoalbuminemia

Answer 10

1: Wasting due to acute malnutrition

The Waterlow criteria was developed to determine the degree of malnutrition in children. These categorization systems compare actual weight and length with expected standards (for example the 50% on the CDC growth chart). Degree of undernutrition is divided into 4 levels: normal, mild, moderate, and severe. The Waterlow criteria take into account both weight and length. Weight for length is evaluated as an index of wasting due to acute malnutrition. Length/age is evaluated as an index of stunting due to chronic malnutrition.

Question 11

Question: 11 

What is the suggested daily amount of potassium required for maintenance in an infant receiving parenteral nutrition?

1: 0.8-1 mEq/kg

2: 2-4 mEq/kg

3: 5-6 mEq/kg

4: 7-8 mEq/kg

Answer 11


2: 2-4 mEq/kg


The suggested daily amount of potassium is 2-4 mEq/kg for preterm infants, term infants, and children.

Question 12

Question: 12 

What is the daily maintenance fluid requirement for a 5 kg infant?

1: 300 mL

2: 500 mL

3: 700 mL

4: 1000 mL

Answer 12


2: 500 mL

The Holliday-Segar method estimates caloric expenditure in fixed weight categories; it assumes that for each 100 calories metabolized, 100 mL of H2O will be required. Fluid rates can be adjusted based on clinical state (e.g., fever, tachypnea). This method is not suitable for neonates 50 kg.). Another way of calculating fluid needs is by way of calculating Body Surface Area (BSA). The BSA method is based on the assumption that caloric expenditure is proportional to BSA .It should not be used for children

Question 13

Question: 13 

On radiographic examination, a pediatric patient is found to have osteopenia and multiple fractures in various stages of healing. Serum laboratory results show: Calcium: low. Phosphorus: low. Creatinine: normal. Alkaline phosphatase: high. 25-OH vitamin D: Low. 1,25 (OH)2 vitamin D: Low. PTH: high. Which of the following is the most likely diagnosis?

1: Renal tubular acidosis

2: Osteogenesis imperfecta

3: Vitamin D deficiency rickets

4: Vitamin D dependent rickets type 2

Answer 13


3: Vitamin D deficiency rickets


Biochemical findings in Vitamin D deficient rickets include low or normal serum calcium, low or normal serum phosphorus, high alkaline phosphatase, increased parathyroid hormone and low 25(OH) Vitamin D levels. 1,25 (OH) Vitamin D levels will be low to normal. The main difference between Vitamin D deficient rickets and Vitamin D dependent type 2 rickets will be that 1,25 (OH) Vitamin D levels will be elevated in the latter. Renal tubular acidosis would be reflected through abnormalities in serum creatinine and anion gap. Osteogenesis imperfecta is a genetic disease that is characterized by multiple bone fractures, short stature and is diagnosed by physical exam. In osteogenesis imperfecta, results from routine laboratory studies are usually within reference ranges.

Question 14

Question: 14

What is the recommended daily supplemental enteral iron dose for preterm infants, one month after birth?

1: 0.5-1 mg/kg/d

2: 1-2 mg/kg/d

3: 2-4 mg/kg/d

4: 5-6 mg/kg/d


Answer 14

3: 2-4 mg/kg/d

The rate of growth and erythropoiesis are noted to slow down soon after birth. During such circumstances, iron requirements are lower. An exogenous source of 2-4 mg/kg/day of iron is recommended during the period of stable growth, beginning at 4-8 weeks and continuing until 12-15 months of age. The American Academy of Pediatrics recommends that infants not receiving human milk receive an iron-fortified formula and that preterm infants receive at least 2 mg/kg per day of elemental iron from 1-12 months of age.

Question 15

Question: 15 

What trace element should be monitored in a child with chronic diarrhea?

1: Iron

2: Zinc

3: Copper

4: Selenium

Answer 15

2: Zinc


WHO defines acute diarrhea as less than 14 days in duration and persistent diarrhea episodes as 14 days or longer in duration. Some experts use “Chronic” to describe episodes lasting more than 30 days. Mortality from acute diarrhea is primarily due to fluid loss and dehydration, whereas the patient with persistent diarrhea is also at higher risk of acute and chronic under nutrition, micronutrient deficiencies, persistent diarrhea-associated infections. Although some studies suggest that zinc does not significantly reduce stool output or the duration of diarrhea, the overwhelming bulk of evidence, however, continues to support empiric zinc therapy for childhood diarrhea in low income countries. Recent studies demonstrate that zinc supplementation decreases the duration of diarrheal episodes, risk of hospitalization, all-cause mortality, and diarrheal mortality, with an estimated decrease in mortality of 23%. WHO /UNICEF recommendation for zinc supplementation includes the following: 20mg of zinc per day for 10-14 days for children with acute diarrhea and 10mg per day for infants under six months of age to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months.

Question 16

Question: 16 

Which of the following is recommended to prevent vitamin D deficiency in a 1-month-old infant fed human milk?

1: Supplement with 100 IU vitamin D per day

2: Supplement with 200 IU vitamin D per day

3: Supplement with 300 IU vitamin D per day

4: Supplement with 400 IU vitamin D per day

Answer 16


4: Supplement with 400 IU vitamin D per day

There are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase risk of skin cancer. The recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed. It is now recommended that all infants have a minimum daily intake of 400 IU of vitamin D beginning soon after birth.

Question 17

Question: 17

A seven month-old infant fed reconstituted infant formula and other age-appropriate complementary foods may be at risk of over-supplementation with which of the following?

1: Vitamin A

2: Fluoride

3: Vitamin E

4: Iron

Answer 17


2: Fluoride

During normal enamel maturation, the increased mineralization in the developing tooth is accompanied by the loss of matrix proteins that are secreted early in development. Sufficiently high levels of fluoride can disrupt this process and increase enamel porosity. The greater the amount of fluoride intake during development, the greater the prevalence of enamel fluorosis. The estimated risk of enamel fluorosis related to fluoride intake from reconstituted infant formula is positively associated with the fluoride concentration in the drinking water.

Question 18

Question: 18 

Non-nutritive sucking should be used in the enterally fed neonate less than 32 weeks corrected gestational age to promote

1: mother/child bonding.

2: weight gain.

3: correct development of facial and jaw muscles.

4: oral feeding when developmentally appropriate.

Answer 18

4: oral feeding when developmentally appropriate.
The ability to suck and swallowing is not fully coordinated until 32 to 34 weeks gestation. Non-nutritive sucking during tube feeding improves digestion of enteral feedings. Non-nutritive sucking is thought to stimulate the secretion of lingual lipase, gastrin, insulin and motilin through vagal innervation in the oral mucosa. Although the infant may not be receiving nutrients orally, the practice of non-nutritive sucking may prevent the subsequent development of an oral aversion when the child is physiologically capable of oral feeding.

Question 19

Question: 19 

Which of the following is NOT a contraindication to nasogastric tube feedings in a pediatric patient with cystic fibrosis?

1: Chronic sinusitis

2: Chronic otitis

3: Pancreatic insufficiency

4: Need for long term nutrition support

Answer 19

3: Pancreatic insufficiency


While cystic fibrosis is associated with pancreatic insufficiency, pancreatic enzymes are given simultaneously to assist with adequate absorption of nutrients. Therefore, nasogastric tube (NGT) feedings are not contraindicated in CF patients suffering from pancreatic insufficiency. Contraindications to NGT feeding include upper airway secretions, nasal polyps, recurrent sinusitus or otitis. Patients who will require long term nutrition support should be evaluated for permanent enteral access placement.

Question 20

Question: 20

Which of the following is the BEST indication for use of a soy-based infant formula?

1: Diarrhea

2: Cow’s milk protein allergy

3: Galactosemia

4: Regurgitation with feeds

Answer 20

3: Galactosemia

Infants with acute diarrhea,usually associated with gastroenteritis, can develop secondary lactase deficiency, but a soy formula is not recommended in those instances. Since a high percentage of children who are allergic to cow’s milk protein will also be allergic to soy protein, the American Academy of Pediatrics now recommends a trial use of either a hydrolyzed or free amino acid-containing formula. Galactosemia is an inborn error of metabolism that affects the body’s ability to metabolize galactose. Currently, the only way to treat galactosemia is to eliminate galactose from the diet. Soy-based infant formulas are used as substitutes for milk in galactosemia. The galactose content (approximately 20mg/L) of lactose-free cow’s milk infant formula is considerably higher than soy and hypoallergenic formulas; therefore lactose-free cow’s milk formula is not recommended for treatment of galactosemia. Soy protein-based formulas have no role in preventing allergy or in management of non-specific gastrointestinal symptoms, e.g., infantile colic and regurgitation.

Question 21

Question: 21 

Which of the following concentrations is considered to be an upper limit for the osmolality of infant formulas to avoid tolerance issues?

1: 460 mOsm/kg

2: 360 mOsm/kg

3: 260 mOsm/kg

4: 560 mOsm/kg

Answer 21

1: 460 mOsm/kg
Recommendations for infant formulas are an osmolality of less than 460 mOsm/kg. The osmolality of standard infant formulas at a caloric density of 20 kcal/oz generally falls below this limit with a range of 200 - 380 mOsm/kg. Hydrolyzed protein and free amino acid containing infant formulas have a slightly higher osmolality due to their smaller particle size (330-370 mOsm/kg). The osmolality of a 30 calorie per ounce concentrated standard infant formula is approximately 450 mOsm/kg. The addition of a carbohydrate modular to increase caloric density of formula will increase the osmolality of the formula while the addition of a fat modular will not.

Question 22

Question: 22 

What distinguishes Gastroesophageal Reflux (GER) from Gastroesophageal Reflux Disease (GERD) in infants?

1: GERD is characterized by the presence of significant complications

2: GER is associated with failure to thrive

3: GER is associated with arching of the back and irritability with no other symptoms

4: GERD typically requires surgical fundoplication


Answer 22

1: GERD is characterized by the presence of significant complications

GER is a frequently encountered problem in infancy and it commonly resolves spontaneously. GER is not associated with significant complications and many times these infants are referred to as “happy spitters”. GERD on the other hand is associated with significant complications including weight loss or failure to thrive, feeding difficulties, arching of the back, or irritability. Surgical intervention with fundoplication for treatment of GERD is considered only after other therapies have failed.

Question 23

Question: 23 

Which of the following is FALSE regarding regurgitation in infants?

1: Regurgitation is rare in infants

2: Regurgitation in neonates is related to relaxation of the lower esophaleal sphinter

3: regurgitation is usually transient and will resolve around 7 – 12 months of age

4: Regurgitation is associated with delayed gastric emptying

Answer 23

1: Regurgitation is rare in infants

Regurgitation is very common in infants and does not necessarily signify a problem. Common causes of reflux in children receiving enteral nutrition include rapid administration of enteral formula, delayed gastric emptying, or tube migration into the esophagus. Regurgitation usually will resolve around 7-12 months of age with maturation of the lower esophageal sphincter.

Question 24

Question: 24 

Which of the following is TRUE regarding aspiration in critically ill children?

1: The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research

2: Increased gastric residuals are directly related to increased risk for aspiration

3: Children have strong coordination of pharyngeal muscles, making aspiration less likely than in adults
4: Children have strong cough reflex which helps protect them from aspiration

Answer 24

1: The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research

The actual incidence of aspiration directly caused by enteral nutrition is difficult to determine because there have not been standardized definitions if what constitutes aspiration, nor have there been adequate descriptions in all studies of the actual cause of aspiration in each particular patient. Increased gastric residuals have not been linked to an increased risk for aspiration. Critically ill children actually have decreased strength and coordination of pharyngeal muscles and a weak cough reflex making aspiration more likely.

Question 25

Question: 25 

Which of the following best describes the appropriate use of powdered infant formula in healthcare facilities?

1: Freeze open containers and discard after 30 days from opening

2: Refrigerate open containers and discard after 30 days from opening

3: Use interchangeably with comparable sterile liquid formulations

4: Use only when alternative sterile liquid products are not available and when clinically necessary

Answer 25


4: Use only when alternative sterile liquid products are not available and when clinically necessary
Powdered formulas are not sterile. Powdered infant formulas should only be used in health care facilities when clinically necessary and when alternative commercially sterile liquid products are not available. When there are no other alternatives to infant formula powder, clinicians need to be aware of potential risks with use of powdered formulas for immunocompromised patients.

Question 26

Question: 26 

What is the hang time for expressed human milk when used for continuous enteral feedings?

1: 2 hours

2: 4 hours

3: 8 hours

4: 12 hours

Answer 26

2: 4 hours

Expressed human milk is never sterile and contains a variety of normal skin flora. Contamination can occur during milk expression and storage, during the preparation and mixing of ingredients, and while assembling and handling feeding systems. To reduce potential for contamination, feeding systems that include bags, syringe, or tubing should never be reused, and feeding systems should not be used for more than 4 hours for neonates or immunocompromised infants in the hospital setting.

Question 27

Question: 27 

A 4-month-old male has acute onset of diarrhea for 48 hours. His parents noticed that he hasn’t been wetting as many diapers and his mucous membranes are slightly dry. His anterior fontanel is soft and not sunken. He normally ingests milk based formula ad lib. Which of the following is the most appropriate nutrition intervention for this infant?

1: 1/2 strength infant formula

2: Oral rehydration therapy

3: Full strength soy formula

4: Short course of parenteral nutrition

Answer 27

2: Oral rehydration therapy
An infant who is mildly dehydrated from diarrhea is likely suffering from a viral gastroenteritis that will resolve in 72-96 hours. An otherwise healthy infant with acute dehydration can receive adequate fluid and electrolyte replacement with oral rehydration solutions. A short course of oral rehydration therapy is the preferred treatment. Starting parenteral nutrition is not an appropriate treatment option. Return to an age-appropriate and healthy diet early in the course of diarrheal illness is superior to providing diluted formula or clear liquids. Infants provided human milk ad lib should continue to be fed the human milk. Infants should be monitored for clinical indications that dehydration is worsening. Sunken eyes, sunken fontanelle, loss of skin turgor and dry mucous membranes are signs of moderate dehydration.

Question 28

Question: 28 

What should be the MAXIMUM parenteral dextrose infusion rate for a term infant?

1: 4-8 mg/kg/min

2: 8-12 mg/kg/min

3: 14-18 mg/kg/min

4: 18-22 mg/kg/min

Answer 28

3: 14-18 mg/kg/min

In order to meet the energy needs of the growing neonate, 90-120kcal/kg/d is often required. In a stable infant, parenteral support should provide 2-3g/kg/d of protein (10-20% of kcals),

Question 29

Question: 29 

In an infant with adequate energy intake, what is the MINIMUM amount of fat emulsion containing long chain fatty acids needed to prevent essential fatty acid deficiency?

1: 0.2-0.4 g/kg/day

2: 0.5-1.0 g/kg/day

3: 1.1-1.5 g/kg/day

4: 1.8-2.0 g/kg/day

Answer 29

2: 0.5-1.0 g/kg/day

Essential fatty acid deficiency can be prevented in pediatric patients receiving parenteral nutrition support by providing approximately 4% of total calories as fat. In most cases intravenous fat emulsion at 0.5-1.0 g/kg/day will meet this goal.

Question 30

Question: 30 

Standard parenteral amino acid solutions available for neonates differ from standard adult parenteral amino acid solutions by having a higher content of

1: cysteine.

2: phenylalanine.

3: taurine and tyrosine.

4: methionine and glycine.

Answer 30


3: taurine and tyrosine.
Taurine and tyrosine are considered essential amino acids in neonates because of enzyme immaturity. Phenylalanine, methionine, and glycine are actually given in smaller amounts to neonates compared to adults, not higher. Cysteine is also considered an essential amino acid for infants but is unstable in aqueous solution so it is therefore added immediately prior to administration. It is not a component of standard parenteral amino acid solutions.

Question 31

Question: 31

In a preterm infant, which of the following amino acids is separately added to parenteral nutrition solutions due to solubility concerns?

1: Glycine

2: Cysteine

3: Methionine

4: Phenylalanine

Answer 31

2: Cysteine

In adults, cysteine can be synthesized from methionine via a liver-specific transsulfuration pathway. The enzyme necessary for this synthesis is not present in adequate amounts in preterm infants. Therefore, cysteine is considered likely to be an essential amino acid for preterm infants. It is not included in usual amino acid solutions because of solubility concerns. However, it can be added as cysteine HCl at a dose of 40 mg per gram of amino acids.

Question 32

Question: 33 

Immediately following neonatal cardiac surgery, which of the following is the best estimate of parenteral caloric requirements?

1: 90-100 kcal/kg/day

2: 120-170 kcal/kg/d

3: 55-60 kcal/kg/d

4: 100-110 kcal/kg/d

Answer 32

3: 55-60 kcal/kg/d

Though growth is often the primary goal in neonatal nutrition, growth cannot occur until recovery from the stress response has begun. Critically ill and postoperative neonates have significantly lower energy needs compared with healthy neonates due to absence of growth, decreased activity, and reduction in insensible losses during stress states. Indirect calorimetry (IC) is recommended when possible but, if IC is not available, the basal energy/resting energy expenditure (REE) should be used for nutrition support provision.

Question 33

Question: 34 

Which of the following therapies would be considered most appropriate in the nutritional management of chronic lung disease?

1: Use of concentrated formula

2: Use of a high fat, low carbohydrate formula

3: Use of a hydrolyzed protein formula

4: Use of an MCT oil predominant formula

Answer 33

1: Use of concentrated formula

Infants with chronic lung disease often have high calorie needs due to gastroesophageal reflux, emesis, chronic infections, and increased work of breathing. Use of a concentrated formula allows for provision of adequate nutrition while restricting fluid intake. Fluid restriction is indicated due to fluid build up around the heart and lungs. The use of low carbohydrate formulas, hydrolyzed protein formulas, or MCT oil predominant formulas are not indicated for use for treatment of chronic lung disease.

Question 34

Question: 35 

Pancreatic enzymes supplemented at high doses in children with cystic fibrosis could result in

1: steatorrhea.

2: meconium ileus.

3: fibrosing colonopathy.

4: cystic fibrosis related diabetes.

Answer 34


3: fibrosing colonopathy.

Pancreatic enzymes are used to increase nutrient absorption and decrease the presence of steatorrhea. High dose enzyme usage may result in strictures of the ascending colon, also known as fibrosing colonopathy. Enzymes should be used at less than 10,000 units of lipase/kg/day. Cystic fibrosis related diabetes is secondary to mucus obstruction of pancreatic beta cells, which prevents insulin secretion and may lead to beta cell destruction. While meconium ileus has similar symptoms as fibrosing colonopathy, including intestinal obstruction, mass in the right lower quadrant, and abdominal pain, it is not caused by high dose enzyme therapy.

Question 35

Question: 36 

In 2010, the Institute of Medicine (IOM) concluded that available scientific evidence supports a key role of calcium and vitamin D in

1: cancer outcome.

2: skeletal health.

3: cardiovascular disease outcome.

4: all of the above.

Answer 35


2: skeletal health.

The IOM conducted a thorough review of the evidence for both skeletal and extraskeletal outcomes in an effort to determine population needs for calcium and vitamin D. The committee concluded that sufficient evidence exists to support a cause-and-effect relationship between calcium and vitamin D and skeletal health. Evidence was inconsistent for extraskeletal outcomes, including cancer, cardiovascular disease, diabetes, and autoimmune disorders. Based on bone health evidence, the Recommended Dietary Allowance (RDA) for calcium is 700 mg/day for children 1-3 years of age, 1,000 mg/day for children 4-8 years of age and 1,300 mg/day for children and adolescents 9-18 years of age. The RDA for vitamin D for children 1-18 years of age is 600 IU/day. The RDA for vitamin D was determined based on conditions of minimal sun exposure due to the variability of vitamin D synthesis in the skin from ultraviolet light and the risks of skin cancer.

Question 36

Question: 37 

The use of Lactobacillus GG in pediatric practice has been found to be MOST effective in

1: treating infectious diarrhea.

2: reducing the incidence of NEC.

3: prolonging time to remission in children with Crohn’s.

4: eradicating heliobacter pylori infection.

Answer 36

1: treating infectious diarrhea.

Diarrhea is common in infants and children and contributes significantly to morbidity and mortality, especially in developing countries. Lactobacillus GG, which is a component of normal human intestinal flora, has been studied frequently in regard to it’s potential antidiarrheal properties. A meta-analysis of randomized, controlled studies concluded that Lactobacillus GG is a safe and effective as a treatment for children with acute infectious diarrhea. Current research does not support use of Lactobacillus GG as therapy for treatment of NEC, Crohn’s, or heliobacter pylori in infants or children, however research has been done with other strains of probiotics in NEC, Crohn’s and heliobacter pylori.

Question 37

Question: 38 

An infant has a complete ileal resection with preservation of the ileocecal valve. Of the following, the primary nutrition-related concern will be

1: decreased vitamin B12 absorption.

2: water soluble vitamin malabsorption.

3: dumping syndrome.

4: protein malabsorption due to decreased cholecystokinin secretion.

Answer 37

1: decreased vitamin B12 absorption.

The jejunum is the primary site of absorption of most nutrients, including water soluble vitamins. The duodenum and jejunum are the primary sites of cholecystokinin and secretin secretion. The ileum has greater adaptive capacity than the jejunum. The ileum also absorbs vitamin B12 and bile salts. With ileal resection, the bile salt pool is depleted and fat absorption is reduced. In addition, the loss of bile salts into the colon reduces the ability of the colon to reabsorb water and salt, resulting in increased diarrhea. Resection of the ileocecal valve leads to decreased transit time and an influx of nutrients into the large intestine, which can result in malabsorption. Dumping syndrome is most likely to develop if all of part of the stomach has been removed.

Question 38

Question: 39 

Preterm infant formula or fortified human milk is used for premature infants during their first year of life. What is the rationale for this?

1: Preterm formula contains a higher percentage of carbohydrate as lactose, compared to term formula

2: After the first month, unfortified human milk may contain inadequate protein for the premature infant

3: Term formula contains more medium chain triglycerides than desired

4: Preterm formula is easier to absorb than unfortified human milk

Answer 38

2: After the first month, unfortified human milk may contain inadequate protein for the premature infant

Preterm formulas contain 40-50% of the carbohydrate calories as lactose (50-60% as glucose polymers), which is a lower load of lactose to the premature infant compared to standard term infant formulas (100% lactose). Standard infant formulas contain only long chain fatty acids. Preterm formulas contain 40-50% of fat calories as medium chain triglycerides, which are easier to absorb than long chain fatty acids as they do not require pancreatic lipase or bile salts for digestion or absorption. Preterm human milk often contains a higher concentration of protein. However, the protein concentration decreases by 28 days of lactation. Human milk fortifiers should be added to human milk to meet the protein, calcium, phosphorous and sodium needs of the rapidly growing premature infant. Nutrients in human milk (fortified or unfortified) are more readily absorbed than nutrients in preterm or term formula.

Question 39

Question: 40 

Which of the following does NOT describe the use of minimum enteral feeds in preterm neonates?

1: Prevents gut atrophy

2: Increases the risk of necrotizing enterocolitis

3: Improves feeding tolerance and time to full enteral feeds

4: Should be started as soon as medically feasible

Answer 39

2: Increases the risk of necrotizing enterocolitis


The development of necrotizing enterocolitis (NEC) is a concern in the neonate. Although the etiology of NEC remains unclear, it often occurs in infants who are being fed via the gastrointestinal tract. Therefore, a main strategy for reducing the risk of NEC has been to withhold enteral feeds for prolonged periods of time. Some studies now refute this practice by demonstrating that early initiation of minimum enteral feeds does NOT increase the risk of NEC and showed benefits such as a shorter time to full enteral feeds, faster weight gain, improved feeding tolerance, decreased length of hospitalization and reduced incidence of serious infections in low birth weight and very low birth weight infants. When medically possible, minimum enteral feeds can begin on the day of birth, with the preferred feeding being human milk.

Question 40

Question: 41 

Exclusive provision of specialized nutrition support (SNS) can induce remission in up to 85% of children with recently diagnosed Crohn’s disease. Which form of SNS is recommended for use as first-line therapy?

1: Polymeric enteral formula

2: Elemental enteral formula

3: Parenteral nutrition

4: Gluten-free diet

Answer 40

1: Polymeric enteral formula

Pediatric Crohn’s disease has an adverse effect on growth and nutritional status. Corticosteroids are often used as first-line therapy but can further depress growth and negatively impact bone mineral density and mucosal healing. Exclusive enteral nutrition (EEN) has been shown to induce remission in up to 85% of children with newly diagnosed Crohn’s disease and NASPGHAN recommends that EEN be supported as a first-line induction therapy in pediatric Crohn’s disease. Both elemental and polymeric enteral formulas have been used for EEN, but no advantage to elemental formula has been noted and polymeric formulas are typically less expensive and have better tolerance for oral administration. Also, research suggests that use of polymeric formula rather than elemental formula may promote higher weight gain.

Question 41

Question: 42 

Which of the following is NOT a common clinical symptom of celiac disease in childhood?

1: Failure to thrive

2: Constipation

3: Precocious puberty

4: Anemia

Answer 41

3: Precocious puberty

Common symptoms of celiac disease in childhood include diarrhea, constipation, chronic abdominal pain, abdominal distention, vomiting, short stature, weight loss, inadequate weight gain, dental enamel defects, dermatitis herpetaformis, reduced bone mineral density, iron deficiency anemia, fatigue, migraines, and joint pain. Delayed puberty, not precocious puberty, is a symptom of celiac disease. Upon symptom identification, gluten need to remain in the diet until after serology testing and biopsy are completed. Intestinal biopsy is needed for formal diagnosis.

Question 42

Question: 43 

A 2-month-old infant, who has been exclusively fed with cow’s milk based formula develops a full body rash. Which of the following would be the most appropriate next step?

1: Switch to a soy protein based formula

2: Switch to a high MCT oil formula

3: Switch to a protein hydrolysate based formula

4: Switch to a lactose free cow’s milk based formula

Answer 42

3: Switch to a protein hydrolysate based formula

Since the child could have a cow’s milk protein allergy, a correct initial response would be to switch to a protein hydrolysate or free amino acid formula. Since a percentage of children who are allergic to cow’s milk protein will also be allergic to soy protein, the American Academy of Pediatrics now recommends a trial use of either a hydrolyzed or free amino acid containing formula.

Question 43

Question: 44 

The biochemical defect in phenylkenonuria (PKU) is a functional deficiency of the liver enzyme phenylalanine hydroxylase, which catalyzes the para-hydroxylation of phenylalanine to yield what amino acid?

1: Threonine

2: Alanine

3: Methionine

4: Tyrosine

Answer 43


4: Tyrosine
The deficiency of phenylalanine hydroxylase in classic PKU prevents the hydroxylation of phenylalanine to tyrosine which causes a build up of phenylalanine in the blood and a subsequent deficiency of tyrosine. Provision of a phenylalanine restricted, tyrosine supplemented diet has been shown to improve outcomes in people with this hereditary metabolic disorder.

Question 44

Question: 45 

Biliary atresia in infancy is most frequently associated with which of the following?

1: Fat malabsorption

2: Chylothorax

3: Zinc Deficiency

4: Essential fatty acid deficiency

Answer 44

1: Fat malabsorption
Biliary atresia, or atrophy of the bile ducts, causes obstruction of bile flow from the liver into the biliary system and small intestine. Therefore, there is a significant decrease in the concentration of intraluminal bile acids that are needed for micelle formation and fat absorption. The result is fat and fat soluble vitamin malabsorption. Essential fatty acid deficiency has been associated with biliary atresia when an MCT oil predominant without adequate LCT formula was used in dietary management. While zinc deficiency may occur due to chronic malnutrition, cirrhosis, or chronic stress, this deficiency is difficult to assess and detect due to laboratory limitation.

Question 45

Question: 46 

Which of the following is characteristic of cachexia in pediatric oncology patients?

1: Gradual weight loss

2: Maintenance of lean body mass at the expense of body fat

3: Decrease in energy expenditure

4: Progressive wasting of lean tissue and body fat

Answer 45

4: Progressive wasting of lean tissue and body fat
In contrast to prolonged fasting or starvation, cachexia in children with cancer is an advanced state of wasting characterized by excess depletion of skeletal muscle mass and adipose tissue. Mechanisms of protein conservation and decreased energy expenditure that allow prolonged survival in the chronic fasting state appear to be lost or inhibited in cancer.

Question 46

Question: 47

Which of the following methods of estimating energy requirements in critically ill children is LEAST accurate when compared to resting energy expenditure measurement by indirect calorimetry?

1: Schofield Equation
2: White Equation

3: World Health Organization Equations

4: Recommended Dietary Allowance (RDA) for energy

Answer 46

4: Recommended Dietary Allowance (RDA) for energy
In pediatric intensive care patients, predictive equations for energy expenditure yield results that are not consistent with measured energy expenditure. Provision of nutrition support based on inaccurately estimated energy requirements has been shown to result in significant under or overfeeding.

Question 47

Question: 48 


Nutrition therapy for pediatric patients with

Answer 47

1: oral intake of high calorie, high protein diet.

Small burns (20% TBSA generally cannot meet their nutrient needs by oral intake alone.

Question 48

Question: 49 

Which of the following is a metabolic alteration noted during the ebb response following burn injury to a pediatric patient?

1: Elevated catecholamines

2: Decreased resting energy expenditure

3: Elevated plasma insulin

4: Anabolism

Answer 48

2: Decreased resting energy expenditure

The ebb response following burn injury lasts 3-5 days and includes depressed resting energy expenditure, hyperglycemia, low plasma insulin, loss of plasma volume, decreased oxygen consumption, decreased blood pressure, reduced cardiac output, and decreased body temperature. Elevated catecholamines and elevated or normal plasma insulin are observed in the acute phase of the flow response, along with hyperglycemia, elevated glucagon and glucocorticoids, high glucagon-to-insulin ratio, catabolism, increased body temperature, increased cardiac output, redistribution of polyvalent cations such as zinc and iron, mobilization of metabolic reserves, increased urinary excretion of nitrogen, sulphur, magnesium, phosphorus and potassium, and accelerated gluconeogenesis. After the ebb phase, these metabolic alterations occur quickly, and the acute phase peaks between the 6th and 10th day following burn injury. The transition from acute to adaptive phase of the flow response is gradual. Anabolism is not established until the adaptive phase of the flow response.

Question 49

Question: 50 

Which of the following is considered to be diagnostic of infantile anorexia?

1: Refusal to eat adequate amounts of food for >1 month

2: Failure to eat adequately associated with childhood depressive disorder

3: Failure to gain weight after a traumatic event

4: Chronic weight loss associated with a malabsorptive disorder

Answer 49

1: Refusal to eat adequate amounts of food for >1 month
Infantile anorexia is characterized by a child’s refusal to eat adequate amounts of food for at least 1 month. Children with infantile anorexia generally do not communicate that they are hungry, lack interest in food and eating and exhibit growth deficiency. This disorder is not due to an associated gastrointestinal disorder or other medical condition and does not follow a traumatic event. Onset typically occurs between 6 months to 3 years of age and often occurs during the transition to spoon- and self-feeding. Treatment includes understanding the child’s temperament and level of arousal, establishing a regular feeding schedule and incorporation of behavioral techniques and feeding guidelines.

Question 50

Question: 32 

What is the recommended intake of selenium for term infants receiving long-term total parenteral nutrition?

1:

Answer 50


2: 2 mcg/kg/day
Selenium is active as an antioxidant and is also vital in central nervous system development in the infant. Standard infant and pediatric trace element commercial products do not contain selenium. Selenium supplementation is recommended when a pediatric patient is on total parenteral nutrition for >1 month. Assuming normal organ function, term neonates weighing 3 to 10 kg on long-term parenteral nutrition require 2 mcg/kg/day of selenium. Selenium intake should be reduced in the presence of renal dysfunction.