Pediatric patients

Question 1

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

1: 4 month-old exclusively breast fed term infant
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 breast milk is low in iron content, it is very efficiently absorbed. Exclusively breast fed infants 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.

References:

Committee on Nutrition. Iron. In: Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Elk Grove Villiage, IL: American Academy of Pediatrics; 2008:403-422.

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 six 10 ounce sodas per day. What mineral may she be deficient in?

1: Calcium
2: Phosphorus
3: Magnesium
4: Potassium

Answer 2

1: Calcium

Fruit juices and soft drinks are increasingly consumed by young children. Soft drinks have been shown to replace milk in the diet which can have a negative impact on nutrient intakes, particularly calcium.

References:

Committee on Nutrition. Adolescent Nutrition. In:Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Elk Grove Villiage, IL: American Academy of Pediatrics; 2008:175-181.

Question 3

A child with cerebral palsy is admitted to the hospital for a fundoplication and a gastric feeding tube. Together, these procedures are 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.

References:

Farrell M. Gastrointestinal disorders of infancy and childhood (with nutrition support and probiotics). In: Ekvall SW, Ekvall VK, eds. Pediatric Nutrition in Chronic Diseases and Developmental Disorders:Oxford , NY: Oxford University Press; 2005:243-253.

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.

References:

Wagner CL, Greer FR, American Academy of Pediatrics Section on Breastfeeding, American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children and adolescents. Pediatrics; 2008;122(5):1142-52.

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 conistent 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.) Unfortunately, indirect calorimetry is not widely used, especially in pediatric facilities.

References:

Mehta NM, Compher C, ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child. JPEN.2009;33:260-276.

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: normal weight.
3: at risk for becoming 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 overweight. 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 or a BMI greater than 30, whichever is lower, are classified as “obese”.

References:

Appendix: Expert committee recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity. June 6, 2007. Available at: http://www.ama-assn.org/amal/pub/upload/mm/433/ped_obesity_recs.pdf. Accessed Nov. 26, 2007.

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.

References:

Hohi-ud-din R. Drug and chemical induced cholestatis. Clin Live Dis. 2004;8:95-132.

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

2. 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.

References:

Fenton TR. A new growth chart for preterm babies: Babson and Benda’s chart updated with recent data and a new format. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=324406. Accessed 10/31/2006.

Question 9

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 9

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.

References:

Corrales KM, Utter SL. Growth Failure. In: Samour, P, King K, eds. Handbook of Pediatric Nutrition. 3d ed. Sudbury, Ma: Jones and Bartlett Publishers; 2005:391-406.

Question 10

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 10

2: 2-4 mEq/kg

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

References:

Task Force for the Revision of Safe Practices for Parenteral Nutrition, Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, Seres D, Guenter P. Safe Practices for Parenteral Nutrition. JPEN. 2004; 28:S39-S70.

Question 11

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 11

Body Weight Fluid Requirement:

1st 10 kg-100 mL/kg/d; 2nd 10 kg- 50 mL/kg/d; Each additional kg-20 mL/kg/d (<= 50 kg.) or 15 mL/kg (> 50 kg.)

References:

Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy.Pediatrics.1957; 19(5):823-832.

Question 12

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 12

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.

References:

Ladhani S, Srinivasan L, Buchanan C, Allgrove J. Presentation of vitamin D deficiency. Arch Dis Child. 2004;89(8):781-784.

Question 13

What is the recommended daily enteral iron dose for preterm infants?

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 13

3: 2-4 mg/kg/d

Preterm infants have limited stores of iron and need exogenous supplementation. Iron is generally dosed for such infants up to 4 mg/kg/day.

References:

Rao R, Georgieff M. Microminerals. In: Tsang RC, UAUY R, Koletzko B, Zlotkin SH, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. Cincinnati, OH: Digital Educational Publishing, Inc; 2005:277-310.

Question 14

Which of the following trace elements has been used in the treatment of infantile diarrhea?

1: Iron
2: Zinc
3: Copper
4: Selenium

Answer 14

2. Zinc

Deficiency of zinc may play an important role in explaining the high rates of childhood morbidity and mortality in developing countries. Zinc supplementation has been shown to decrease the duration of diarrheal illness. Some suggest that it should be routinely added to diarrhea treatment regimens in places with low dietary zinc intake, although this has not yet been embraced by the World Health Organization.

References:

King CK, Glass R, Bresee J. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm and Reports. 2003;52(RR16):1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm. Accessed 10/31/2006.

Question 15

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

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 15

2. Supplement with 200 IU Vit D per day

A resurgence of vitamin D-deficient rickets in infants continues to be reported in the United States. Breastfed infants who do not receive supplemental vitamin D or adequate sunlight exposure are at increased risk. A state of deficiency occurs months before bone changes are obvious. At one time it was thought sunlight exposure was a consistent, reliable source of adequate vitamin D intake. It is very difficult, however, to determine if sunlight exposure provides adequate vitamin D for an individual breastfed infant. Due to growing concerns about sunlight and skin cancer and the various factors such as sunscreens that negatively affect sunlight exposure, the American Academy of Pediatrics recommends that, starting within the first 2 months of life, all breastfed infants be given a daily pediatric multivitamin containing 200 IU vitamin D.

References:

Wagner CL, Greer FR, American Academy of Pediatrics Section on Breastfeeding, American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children and adolescents. Pediatrics; 2008;122(5):1142-52.

Question 16

A 7 month-old infant fed ready-to-feed infant formula and other age-appropriate complementary foods may benefit from supplementation with which of the following?

1: Vitamin A
2: Fluoride
3: Vitamin E
4: Iron

Answer 16

2: Fluoride

Fluoride supplementation is not necessary prior to 6 months of age. Fluoride supplements may be of some benefit to children living in fluoride-deficient areas. The decision to recommend a fluoride supplement should be based on the total amount of fluoride from all sources available to a child daily. The goal is to maximize protection from caries while minimizing the risk of fluorosis. Ready-to-feed infant formulas do not contain fluoride. At 7 months of age, it is not appropriate to provide and infant with supplemental water.

References:

Committee on Nutrition. Nutrition and Oral Health. In: Kleinman RE, ed. Pediatric Nutrition Handbook, 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008:1041-1056.

Question 17

Nipple feeding and/or nonnutritive oral stimulation should be used in the neonate less than 32 weeks corrected gestational age while being fed enterally to promote

1: mother/child bonding.
2: appropriate swallowing response.
3: correct development of facial and jaw muscles.
4: ability to feed orally when developmentally appropriate.

Answer 17

4: ability to feed orally when developmentally appropriate.

Nipple feeding or nonnutritive oral stimulation during tube feeding should be encouraged. Even though nutrients provided orally may not be available to the child, the practice of nonnutritive oral stimulation may prevent the subsequent development of an oral aversion when the child is physiologically capable of benefiting from oral feeding.

References:

Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2005;19;(4):CD001071.

Question 18

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: NGT feedings cannot be absorbed when pancreatic insufficiency is present
4: Need for long term nutrition support

Answer 18

3. NGT feedings cannot be absorbed when pacreatic insufficiency is present

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

References:

Nevin-Folino N, Miller M. Enteral Nutrition. In: Samour P, King K. Handbook of Pediatric Nutrition Support. 3d ed. Sudbury, Ma: Jones and Bartlett Publishers; 2005:499-524.

Question 19

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 19

3. Galactosemia

Infants with acute diarrhea,usually associated with gastroenteritis, can develop secondary lactase deficiency and may benefit from the short-term usage of a lactose-free formula, but should be re-challenged in order to prevent a pattern of avoiding milk products. Soy-based infant formulas are not necessary in these 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.

References:

Charos TL, Sandhu G. Probiotics. Pediatr Rev. 2006;27(4):137-139.

Question 20

Which of the following 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 20

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 are essentially isotonic with an osmolality around 300 mOsm/kg. Hydrolyzed protein and free amino acid containing infant formulas have a slightly higher osmolality secondary to their smaller particle size (330-370 mOsm/kg). The osmolality of 30 calorie per ounce concentrated standard infant formula is 450 mOsm/kg. The addition of carbohydrate to increase caloric density of formula will increase the osmolality of the formula while the addition of fat will not.

References:

Nevin-Folino N, Miller M. Enteral Nutrition. In: Samour P, King K. Handbook of Pediatric Nutrition Support. 3d ed. Sudbury, Ma: Jones and Bartlett Publishers; 2005:499-524.

Question 21

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 does not typically resolve spontaneously
4: GERD typically requires surgical fundoplication

Answer 21

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. GERD, on the other hand, is associated with significant complications including weight loss or failure to thrive, crying and fussiness during feedings, respiratory problems, and anemia. Surgical intervention with fundoplication for treatment of GERD is considered only after other therapies have failed.

References:

Henry SM. Discerning differences: Gastroesophageal reflux and gastroesophageal reflux disease in infants. Advances in Neonatal Care. 2004; 4:235-247.

Question 22

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 may occur if enteral nutrition is infused too quickly
4: Regurgitation is associated with delayed gastric emptying

Answer 22

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.

References:

Weckwerth JA. Monitoring enteral nutrition support tolerance in infants and children. NCP. 2004;19:496-503.

Question 23

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

2: Formula should be colored with blue food dye if aspiration is suspected
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 23

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 of what constitutes aspiration, nor have there been adequate descriptions in all studies of the actual cause of aspiration in each particular patient. Critically ill children actually have decreased strength and coordination of phar1: The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research
yngeal muscles and a weak cough reflex making aspiration more likely.

References:

Weckwerth JA. Monitoring enteral nutrition support tolerance in infants and children. NCP. 2004;19:496-503.

Question 24

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 comparable sterile liquid formulations are not available

Answer 24

4: Use only when comparable sterile liquid formulations are not available

Powdered infant formulas are not sterile. The powdered formulations should be used only in health care facilities when clinically necessary and when alternative sterile liquid products are not available. When there are no other alternatives to use of powdered formulas, clinicians must realize the potential risk of their use in immunocompromised patients.

References:

Teske S, Robbins S. Formula preparation and handling. In: Robbins ST, Beckes LT, eds. Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities. Chicago, Il: The American Dietetic Association; 2003:31-47.

Question 25

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

1: 2 hours
2: 4 hours
3: 8 hours
4: 12 hours

Answer 25

2: 4 hours

Breast milk is not a sterile fluid. Although it has bacteriostatic properties, the potential for further contamination exists in the collection and storage. Bacterial growth can be substantial when held at room temperature for greater than 4 hours. Therefore, the guidelines have been established for a 4-hour hang time for breast milk.

References:

Sapsford A. Expressed human milk. In: Robbins ST and Beker LT, eds. Infant Feeding: Guidelines for Preparation of Formula and Breast Milk in Health Care Facilities. Chicago, IL: American Dietetic Association; 2003:76.

Question 26

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 depressed. He normally ingests breast milk 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 26

2: Oral rehydration therapy

An infant who is mildly dehydrated from diarrhea is likely suffering from a viral gastroenteritis that will run its course in 72-96 hours. An otherwise healthy and well nourished infant can receive adequate fluid and electrolyte replacement with oral rehydration solutions to manage acute dehydration. A short course of oral rehydration therapy is the preferred treatment; changing formulas and starting parenteral nutrition are not appropriate treatment options. Generally infants can resume their regular feedings (breast milk or formula) fairly quickly. The most important issue here is counseling parents on signs of more serious dehydration if the infant does not tolerate oral rehydration therapy so that a further evaluation can be performed.

References:

Dennehy PH. Acute Diarrheal Disease in Children: Epidemiology, Prevention and Treatment. Infect Dis Clin N Am. 2005;19:585-602.

Question 27

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

1: 4 mg/kg/min
2: 6 mg/kg/min
3: 10 mg/kg/min
4: 12 mg/kg/min

Answer 27

4: 12 mg/kg/min

Preterm infants can usually tolerate 5% dextrose solutions immediately after birth. Concentrations can then be increased gradually to a maximum of 12 mg/kg/min. Provision of glucose at rates greater than 12 mg/kg/min exceeds oxidative capacity of the liver in neonates. Glucosuria is not uncommon in a preterm infant.

References:

Appendix 3. Summary of Reasonable Nutrient Intakes (Mass Units) for Preterm Infants. In: Tsang RC, UAUY R, Koletzko B, Zlotkin SH, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. Cincinnati, OH: Digital Educational Publishing, Inc; 2005:415.

Question 28

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 28

2. O.5-1 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.

References:

Koletzko BV, Innis SM. Lipids. In: Tsang RC, UAUY R, Koletzko B, Zlotkin SH, eds. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd ed. Cincinnati, OH: Digital Educational Publishing, Inc; 2005:97-139.

Question 29

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 29

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.

References:

Anderson D. Nutrition Suport for Neonates. In: Matarese LE, Gottschlich MM, eds. Contemporary Nutrition Support Practice A Clinical Guide. 2nd ed. Philadelphia: Saunders; 2005:344-356.