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Flashcards in CPS Nutrition Deck (55):
1

Which of the following is true of how to introduce solids and complementary foods?
a) should be introduced starting at 4 months of age
b) should start with meats, meat alternatives and iron fortified cereals
c) solids can be delayed to 7 months at parents discretion with no consequences
d) formula is often helpful to helpful to help optimize the growth of healthy babies

b) true to help decrease chance of iron deficiency anemia

start at 6 months of age or a few weeks before, delaying it too much increases the risk of iron deficiency anemia, don't need formula, WHO guide
to be ready: sit up, better head control, lean forward, turn away when full, pick up food
meats and iron fortified cereal should be the first foods introduced, need to mush up the meats

advantage of breastfeeding:
- better cognitive development
- decreased GI infections
-acute OM, respiratory infections, SIDS
-protect against obesity later in life

breastfed infants need 400 units of vitamin D daily

health care professionals should ensure they tell families the unequalled benefit of breastfeeding, the personal, social and economic cost of not breastfeeding and the difficulty to reverse the decision not to breastfeed
can help with selection of formula and how to prepare etc in cases where families choose not to breastfeed


introducing solids too early decreases the duration of breastfeeding

2

Which of the following is a reasonable reason to discontinue breastfeeding?
a) managing colic symptoms
b)improvement of reflux
c)during an episode of gastroenteritis with mild dehydration
d) galactosemia

d) galactosemia is a contradindication
the others are:
- herpes on both breasts
-untreated infectious TB
-severe illness that prevents her from caring for infant
-in Canada HIV since formula feeding is safe

**can continue with hepB (no documented transmission), hepC from cracking nipples is a possibility
- illicit drugs, some radioactive meds and antimetabolites are unsafe so if no alternatives found might need to stop

colic -
some studies have shown reduction in symptoms when mothers have hypoallergenic diet, but small studies, not super convincing evidence
severe colic - 1-2 week trial of cow milk free diet is a good idea, with support from a dietician
currently some theories that gut microflora leads to development of colic, studies in place about probiotics inconclusive so far

gastro - good to rehydrate with breastmilk, shown to decrease the severity, length of rotavirus

3

Which of the following is not a reasonable recommendation for a mother who chooses not to breastfeed?
a) use cow based commercially available infant formula
b) use soy based commercially available infant formula for infants with galactosemia
c) use goat's milk for lactose intolerant infants
d) feed the baby pumped milk if there is no contraindication to breastfeeding

c) goat's milk not acceptable (good paediatrics paper March 15,2010)
- disadvantages/risks include:
- folate deficiency (megaloblastic anemia), breastmilk has much more folate
- metabolic acidosis, hypernatremic dehydration, azotemia leading to severe CNS pathology, kidneys can't handle the solute load
- unpasteurized infection risk - Q fever, toxo, brucellosis, HUS (from E coli )157)

4

Which of the following is an appropriate weight gain for a baby age 0-3 months?
a) 0.3-0.8 kg/month
b) 0.6-1.4 kg/month
c) 0.8-1.8 kg/month
d) 1.2-1.6 kg/month

b) is the answer
from 3-6 months 0.3-0.8 kg/month

5

Which of the following infants is not at risk of iron deficiency in the first 6 months of life?
a) breastfed ex 36 week premature infant weighing 3.1 kg
b) breastfed infant of a diabetic mother
c) breastfed infant of a mother who consumed significant alcohol during pregnancy
d) breastfed infant of a mother with iron deficiency
e) infant fed homemade formulas of evaporated milk or cow milk

a) infants weighing less that 3 kg may need

the others at higher risk of iron deficiency, more studies being done to determine what the approach should be

general consensus s that infants don't need extra iron in 1st 6 months of life, but some evidence now that certain babies at increased risk of iron deficiency

smoking can decrease milk production and impact growth, but benefits of breastfeeding mean that should continue to breastfeed even if smoking, try to smoke outside as much as possible

alcohol - sleep effects, impact taste of milk, neurocognitive impact with heavy drinking

single poor moms least likely to breastfeed, less likely to give vitamin D

6

Which of the following is false of soy based formulas?
a)have isoflavone concentrations roughly 13000x-22000x the serum estradiol concentrations
b) lead to a daily intake of 4-11 mg/kg of phytoestrogens for infants consuming soy based formulas
c) animal studies have shown that they can lead to infertility, abnormal brain and sex organ development, cancer and immune function problems
d) may lead to abnormal thyroid function in healthy infants
e) should not be used in premature infants

d) false - only in infants with congenital hypothyroidism, need to monitor thyroxine levels closely in these infants

isoflavone is the phytoestrogen most commonly found in soy based formulas (include genistein, dadzein, glycetein)
the rest true
risk that these estradiols will affect body functions affected by estradiol
likely inactivated during absorption process (animal studies - most are already inactive anyways (94%) 0-3% of phytoestrogens in active form based on animal studies)
a) vs 50-200x for cow milk formulas
b)compared to 1mg/kg for traditional japanese diet
c) true -
human retrospective study - no difference in cancer risk, reproductive maturity or general health
no difference between men
women had slightly increased asthma/allergy and longer menses; not biologically significant; no overt toxicities observed so far
e true - does not optimally promote growth of premature infants, shouldn't be used for them
overall - no overt harms have been proven potential risks a concern, no discernible benefits
should only be used for galactosemia or children who culturally/religious can't have dairy (before at one point 20% were using)

7

Which of the following is the best formula choice for a child with IgE mediated CMPA?
a) hydrolysed casein formula
b) soy formula
c) goat's milk based formula
d) amino acid based formula

a) such as neonate or nutramigen is the best choice
based on recommendations; however, people often choose soy because cheaper and tastes better
if not tolerated, amino acid based formula is the next best choice (i.e. puramino)
**if you can satisfactorily rule out non IgE CMPA then only can consider soy

soy based formula contraindicated for non IgE mediated CMPA since there is a lot of cross reactivity for soy in these kids
ESPHGAN: soy formula should not be used in less than 6 months old, lots of adverse reactions in this population, >6 months should establish tolerance to soy with challenge test first
gold standard for CMPA diagnosis is double blind, placebo controlled food challenge, hard to do; IgE mediated(i.e. anaphylaxis) vs non IgE mediated (i.e. blood in the stool) - hard to tell the difference ,likely a spectrum of diagnosis , therefore for CMPA then should do hydrolyzed formula
CMPA less likely in breastfed babies

8

Which of the following is not a criteria for the diagnosis of colic?
a) paroxysms of crying that start and stop without an obvious cause
b) episodes of crying last at least 3 hours per day and occur at least 3 times a week for at least 1 week
c) age > 3 months
d) no failure to thrive

c) not a criteria, age

9

Which of the following is true?

a) bottle fed infants are more likely to get colic
b) hypoallergenic diet in breastfeeding mothers may reduce colic symptoms based on some research studies
c) partially hydrolysed formula in formula fed babies may reduce colic symptoms based on research studies
d) soy formula does not reduce symptoms of colic

b) true
- hypoallergenic diet - in breastfed
- one study - removed cow's milk, reduced colic, when reintroduced colic came back
- 2nd study - hypoallergenic diet - no milk, egg, wheat or nuts, colic reduced by 39%
-3rd study - hypoallergenic diet - Absolute risk reduction of 37%

the rest are false

a) false- a crossover study didn't find any difference between bottle and breastfed infants in terms of prevalence of colic

b) partially hydrolysed formula (i.e. gentalese) are not hypoallergenic do not decrease colic due to cow's milk intolerance, need extensively hydrolyzed formula (i.e. neonate) to treat colic, these taste yucky and are expensive
evidence
- one RCT, hydrolyzed casein formula reduced colic , in another hydrolyzed whey formula reduced colic
- another study, amino acid formula reduced crying time
-bovine Ig increased crying time
d) false - studies show that colic symptoms improved - duration of crying with soy formula; however, because it is a frequent allergen in infancy (i.e. cross reacts), should not use to treat CMPA, should only use for galactosemia or babies with cultural/religious reasons for not having milk products

10

Which of the following is not a reasonable treatment for colic?
a) 2 week trial of Neocate formula
b) 2 week trial hypoallergenic diet for breastfeeding mothers
c) 2 week trial of amino acid based formula
d) lactase treatment

d)
lactase treatment
overall limited evidence in the studies that it makes a significant difference, therefore not recommended for the treatment of colic
congenital lactase deficiency is rare

if no change to diet interventions then stop them, also ensure that there is good nutritional support (vitamin D, calcium, calories) when doing them

one study showed that probiotics (lactobacillus) vs simethicone may have a significant effect on decreasing colic symptoms

more studies are needed to assess the role of probiotics in the treatment of colic

overall, not a tone of great studies, dietary interventions reduce colic in a small minority of infants, vast majority shouldn't change the diet

**remember that partially hydrolyzed does not work

11

Which of the following kids is receiving the correct supplemental fluoride treatment?
a) 3 month old who lives in an area with < 0.3 ppm fluoride not receiving any supplementation

c) is the answer
supplemental fluoride only from age of 6 months and only if following conditions:
- fluoride in drinking water < 0.3 ppm
- don't brush teeth (or have them brushed) by guardian 2x daily
- susceptibility to cavities (based on genetics, local patterns etc)

doses (see chart)
0.3ppm none
3 years - 6 years: 0.3 ppm none
> 6 years: 1 mg daily, > 0.3 ppm none

should always dilute fluoride drops and put on teeth
in absence of adequate fluoride exposure,

12

Which of the following is false of fluorosis in Canada?
a) most likely in children

b) highest risk is between 15-24 months of age (secondary teeth? i think they mean the second batch of primary teeth)
80-90% are are minimal, others can be more severe

balance between cavities and fluorosis, decline between 0-0.7, no additional benefit beyond this
if natural concentration is less than 0.3 ppm then need to add fluoride to the water

13

Which of the following is not true of topical fluoride ?
a) increases the chance of fluorosis more than ingested fluoride and also does a better job of preventing cavities
b)inhibits plaque
c) inhibits demineralization
d) enhances remineralization of enamel

a) false - ingested fluoride increases the chance of fluorosis more, but doesn't have much effect on caries; alters the deposition of mineral in enamel formation; topical is the best way to prevent cavities

stages of enamel formation
- In the secretory stage, a protein matrix is laid down and mineral deposition begins. In the transition stage, protein is removed and replaced. In the maturation stage, protein is 95% replaced and mineralization is complete. fluoride interferes with transition and maturation stage this effect of fluoride results in interference with crystal deposition, altered cell modulation and delayed maturation of bone

dental caries - bacteria eats the sugar on tooth, feeds it an makes acid which dissolves the tooth
putting the surface ; coating surface of tooth in 1ppm causes dramatic decrease in enamel solubility

the rest are true
makes the teeth less soluble to acid

toothpastes that are labelled as such contain 0.5 mg of fluoride; pea sized portion is 0.4 mg, full portion 1.0 mg, if swallowed, could get too much fluoride and lead to fluorosis

should state fluoride in all foods/drinks etc

14

Which of the following was not found in a Cochrane review of donor breast milk?
a) reduction of NEC in donor milk which was nutrient fortified
b) decreased growth in the breast fed babies
c) using human donor breastmilk with human based fortifier reduces NEC by 63% in extremely preterm infants

d) false - 92% for surgical NEC; I believe this is part of the Cochrane review also
more studies needed; compared to human milk with standard bovine fortifierNICU - shorter stay, less nec, less colonization by pathogens with expressed breast milk; better neurodevelopment outcomes (although hard to study/control)
7% of children born preterm - mom may not be able to provide milk, far away, stress etc.
Cochrane review - reduction in NEC in donor milk fed babies (compared to formula fed); only 8 studies, different feeding practices though so breast fed infants showed less weight gain


15

Which of the following is not necessary to do in the donor milk process?
a) screen serology of donor for infections including HIV, hepB and hepC and HTLV serological testing and physician consent
b) obtain verbal parental consent prior to giving it
c) screening interview the donor
d) collect, store and pasteurize milk as per the Canadian Food Inspection Agency Guidelines

b) no documented case of disease transmission but never absolute, make sure you have documented WRITTEN consent
no higher risk of allergy than formula feeding
the other steps are needed
treat as human body substance
all human milk banks in N.A. governed by human milk bank association of north america
need medical director and a governing board
also need WRITTEN prescription prior to giving it


16

Which of the following is true ?
a) mothers who drink regularly can donate
b) mothers who smoke can donate
c) mothers who require over the counter medications are permanently excluded from donating
d) repeat serological testing of donors every 6 months
e) only very low birth weight babies qualify for donor milk

d) is true

the others (based on the BC website, now also a bank in Toronto (wasn't there when statement made)
drinking - occasionally - need to wait 12 hours
smoking can't donate, meds - occasional OTC usually can donate after done, but some they can't (i.e. domperidone)

how the milk is made - batched from 4 mothers, milk thawed, bacterial culture is taken, then pasteurized and recaptured. if positive for 104 cFU/ml skin flora before pasteurization or any growth after pasteurization it is discarded; again frozen then when needed it is dispensed and thawed

the rest false -
e) very low birth weight and certain GI surgeries/conditions at discretion of health care team; also has benefits/uses in other places for malabsorption/feeding intolerance, immunodeficiency

17

Which of the following is not inactivated by Holder pasteurization of donor milk?
a) CMV
b) hepatitis B
c) Bacillus
d) staphylococcus aureus

c) Bacillus, a spore forming organism, no inactivated by Holder pasteurization of donor milk
unlike cow milk, it is a rare contaminant of human milk, and is detectable by cultures before and after

inactivates most bacteria (looking at studies, most common bacteria including strep, enterococcus and staph are inactivated) and ALL viruses

18

Which of the following is not significantly altered by the pasteurization of human donor milk?
a) IgG
b) fat soluble vitamins
c) IgA
d) lactoferrin
e) lysosyme

b) fat soluble vitamins

not affected:
carbs, fats, salts
13% of protein content is denatured
fat soluble vitamins unchanged
water soluble vitamins not studied - some shown to degrade after pasteurization

affected:
IGA - (which binds microbes in GI tract) 67% of original activity
IgG antibodies 66%
IgM completely removed
lactoferrin - binds iron in bacteria to reduce growth - reduced
lysozymes - attack bacterial cell walls reduced to 75%
certain cytokines - leads to increased epidermal growth factor, increased proliferation of intestinal epithelial cells

cost effectiveness - likely there is, if any reduction whatsoever in sick NICU NEC babies

should tell parents all the advantages of human breast milk, benefits/risks

19

Which of the following is not a step of the baby friendly initiative ?
a) encourage breastfeeding on a strict schedule
b) no use of pacifiers or artificial nipples
c) practice rooming in
d) show moms how to breastfeed and maintain lactation even when they are separated from their infants

a) false - breastfeed on demand

the rest are steps
also need written policy, should initiate breastfeeding within 30 minutes
train HCP in breastfeeding and educated mothers about benefits of breastfeeding, have breast-feeding support groups
only 12hospitals and 25 Community health centers in Canada have the designation - most in Quebec (has a provincial strategy)
BFI - need to follow 10 steps for 80 percent of women
incorporate as many of these as possible for women who cannot breastfeed; no food or drink other than breastmilk

there is an international code of marketing of breastfeeding substitutes

should have provincial strategy and data collection

20

Which of the following is true?
a) eastern provinces in Canada have the highest breastfeeding practices
b) the majority of Canadian women continue to breastfeed until 6 months
c) Baby Friendly Initiative measures have been shown to significantly increase the duration and exclusivity of breastfeeding
d) PKU is an absolute contraindication to breastfeeding
e) breastfeeding should be stopped for physiological and breastmilk jaundice

c) true
Cuba - 25%-72%
China - 29-72%
American Study - even when implemented 5/10 measures - 68% breastfed at 16 weeks compared to 52% of mothers who didn't

the rest false
a) false - eastern provinces lowest, BC and Yukon are the highest
b) false - high initiation rates (90%) but only a few persist till 6 months (estimate 14-24%)
d) false - used to be seen as such but not breastfeeding is thought to complement low phenylalanine formula with monitoring of phenylalanine levels

contraindications
- HIV in Canada
-cytotoxic chemo during treatment
-radioactive isotopes or radiation treatment - temporarily suspend breastfeeding during treatment course
-classic galactosemia

e) should not

21

Which of the following is an indication to stop breastfeeding?
a) gastroenteritis with campylobacter
b) mastitis with frank pus
c) latent TB
d) herpes lesions on both breasts

d) is an indication, don't feed until the lesions have crusted over

usually continue breastfeeding cause the baby is usually colonized with mom's flora already anyways and stopping breastfeeding removes the protection that comes from mom's antibodies

the others -
mastitis - organisms include staph aureus, strep, e coli; rarely salmonella, mycobacterium,candida, cryptococcus - if frank pus, pump from affected and feed from the other breast until it is healed
gastro (including salmonella, e coli, shigella, campylobacter) - wash hands well
for active TB - wait until mom has received 2 weeks of treatment, and give prophylaxis to the baby (since airborne)

22

Which of the following infections does not require the baby to receive immunoglobulin?
a) hepatitis C
b) varicella
c) hepatitis A
d)hepatitis B

a) hep C does not require
can continue breastfeeding for all the others
varicella - for perinatal varicella, give VZIG
for postnatal varicella consider VZIG
hep A- give immunoglobulin
hepB - vaccine and Ig at birth

CMV - there is a risk of transmission via breastmilk, but term infants have a maternal transferred antibody so no biggie, for perms<32 weeks, more controversial, recent studies say should be fine and to keep breastfeeding

23

Which of the following is the appropriate management for a mom with active TB with a newborn infant?
a) start breastfeeding immediately along with treatment since meds are safe for the baby
b) start breastfeeding after 2 weeks of treatment have been completed and give the baby TB prophylaxis as well as pyridoxine
c) start formula feeding since breastfeeding is contraindicated regardless of treatment
d) none of the above

b) is the answer
can breastfeed when no longer contagious
or has received 2 weeks of treatment
if mom on isoniazid baby should get a multivitamin including pyridoxine (vitamin B6) since the med can lead to deficiencies which have symptoms of peripheral neuropathy and other CNS manifestations
meds ARE safe in breastmilk
if BOTH infant and mother are taking isoniazid, might have concerns for too high concentrations of isoniazid so should talk to a specialist

24

Which of the following meds should be used with caution when breastfeeding?
a) isoniazid
b)chloroquine in a healthy child
c) fluconazole
d) high dose metronidazole

d)high dose metronidazole - take a break of 12-24 hours to let the metronidazole clear (so I guess pump and dump for this time)

isoniazid - is okay, just remember pyridoxine for the baby
chloroquine - don't use if G6PD abnormal
for primiquine should test for G6PD (make sure normal) first
TMP/SMX - use with caution if jaundice of G6PD, also if ill/stressed/prem - usually don't use in super young babies because of risk of kernicterus

chloramphenicol - risk of bone marrow suppression

antivirals - amantadine - can suppress milk production

no routine vaccines are contraindicated for breastfeeding mothers

tetracyclines, fluroquinolones, amino glycosides are not contraindications to breastfeeding

25

Which of the following statements about trans fats is false?
a) are unsaturated fats
b) increase LDL
c) increased HDL
d) increase risk of cardiovascular disease

c)decreased HDL, increase LDL, increased CV risk

trans fats are made by hydrogenation
hydrogenation extends the shelf life of the fat
trans fats no benefit to human heath and are non essential

**some chemistry: saturated fat - hydrogen atoms around each carbon atom
unsaturated - double bond at some point between carbons, have cis and trans form, depending on the arrangement of the carbon double bonds
trans fat - straight chain, can by monounsaturated or polyunsaturated

26

Which of the following foods does not contain trans fats?
a) dairy
b) meat
c) breastmilk
d) veggies

d) veggies

the other 3 do
in breastmilk depends on the mother's diet

27

How much fat can a food item contain and still be considered trans fat free?

to be labelled ‘trans fat free’:
- a food item must contain less than 0.2 g of trans fat per reference amount and per serving, and must be ‘low in saturated fat’ (less than 2 g of saturated fat and trans fat combined per reference amount and per serving).

According to a survey performed in 1995, Canadians had one of the highest dietary intakes of trans fats in the world at 8.4 g/day. This was primarily due to the widespread use of hydrogenated oils in prepackaged foods and for cooking in restaurants, particularly fast food restaurants.

In 2002, Health Canada introduced mandatory nutrition labelling of most prepackaged foods, as well as new and revised requirements for nutrient content claims.

WHO says trans fats should be <1% of total daily intake of calories

28

How much weight gain and height is gained by most children in the first year of life?
a) 7 kg and 21 cm
b) 2.3 kg and 12 cm
c) 12 kg and 24 cm
d)1-2 kg/year and 6-8cm/year

a) 7kg and 21 cm are gained in the first year of life
2.3 kg and 12 cm in the second year
the average 2 year old is 87 cm and 12.3 kg at 2 years of age
between 2-5 years of age, weight gain slows down

29

How much weight gain and height is normal for most children between the age of 2-5?
a)a) 7 kg and 21 cm
b) 2.3 kg and 12 cm
c) 1-2 kg/year and 6-8cm/year
d) 12 kg and 24 cm

c) between 2-5 years of age, weight gain slows down1-2 kg/year and 6-8cm/year, during this time, most children experience a decrease in appetite
parents may mistake average weight (50th percentile) for normal weight; children with smaller builds may have lower energy requirements

Although toddlers and preschoolers vary considerably in their intakes at meals during the day, their total daily energy intake remains fairly constant

30

Which of the following is false?
a) mealtime for toddlers should be no longer than 20 minutes
b) juice is an important part of healthy snacking
c) children should get 1 tablespoon of each food for each year of their age, and if they are still hungry, give more
d) special formulas are not required to supplement diet in otherwise well growing children
e) a decrease in appetite that occurs abruptly and applies to all types of food is more likely to be related to organic disease

b) false - juice should not be part of snacks
snacks should be mid-meals
should not offer if it will interfere with the child's next meal
snacks should be dense in nutrients
should not let kids drink milk/juice all day or graze all day

In other words, parents should choose nutritious food oprovide structured meals and snacks, but allow children to decide how much and what to eat.
break of 10-15 minutes before eating is smart. measure weight, height, compare with previous, and determine weight for height or BMI, if looks well and growing, most often physiological. if specific foods eat one day not the next, more likely to be from expectations, for organic all foods and abruptly



31

Which of the following is the appropriate growth chart to use to monitor growth for children from birth to 5 years of age?
a) WHO chart
b) CDC chart
c) none of the above

a) WHO chart now superseded the CDC charts that were used previously

They represent actual distributions of weight and height according to age and sex, and allow the physician to compare a child’s growth to a reference population.

32

How many children cross one percentage line over the first 2-years of life on the CDC growth charts?
a) 5%
b) 15%
c) 20%
d) 30%

d) 30% of children cross one major percentage line, and 23% cross two percentage lines in the first 2 years of life on the CDC growth charts (Can't be applied to the Who charts, crossing 2 percentiles on this is a big deal since the percentiles are more far apart (3,15, 50 etc))

At birth, growth influenced by intra uterine factors, after, more dependent on the genetic potential, catch up or catch down growth can occur

1st 6 months: BF babies grow faster, the next 6 months formula babies grow faster**

33

What is false of the following statements?
a) in constitutional growth delay, there is decreased linear growth velocity in first 3 years of life
b) it is normal to cross growth percentiles between age 3-5
c)in constitutional growth delay after age 3, there is normal linear growth velocity
d) in constitutional growth delay , the growth after age 3 typically plugs along parallel to or along the lower percentiles of the growth curve

b) false - should not change growth percentile between age 3 and puberty

the rest are true

34

A 2 year old is decreasing percentiles in both height and weight simultaneously. Which of the following is the most likely cause
a) endocrinopathy
b) nutritional problems
c) adjustment towards genetic potential
d) celiac disease

c) adjustment towards genetic potential

endocrinopathy height decreases weight doesn't
nutritional and chronic disease weight decreases first then height is affected

If an underlying condition is detected early, treated appropriately and the child is provided with adequate nutrition, growth failure may be reversible

35

Which of the following is matched incorrectly?poor growth with
a) inadequate intake and celiac disease
b) adequate intake and renal tubular acidosis
c) adequate intake and immunodeficiency
d) increased intake and malabsorption

c) incorrect

caloric intake should be compared to the recommended intake for a child's age

inadequate intake and poor growth: can include celiac, IBD, immunodeficiency, infection - may have symptoms of inadequate growth with less intake, and may have minimal GI symptoms

adequate intake: endocrine disease, renal tubular acidosis, genetic diseases, renal failure

taking in more than needed but still not gaining weight: malabsorption

ask how feeding went from the beginning, how different foods were introduced

36

Which of the following is not a common cause of failure to grow in toddlers
a) decreased intake in an otherwise normal child
b) pancreatic disease
c) cholestatic liver disease
d) diencephalic tumour

d) not COMMON (but is a cause of failure to grow, listed under rare causes, renal tubular acidosis is another rare cause)

the other causes include:
decreased intake (normal child, chronic disease, poor oral skills)
increased energy losses from 1) emesis or 2) malabsorption (secondary to pancreatic disease (CF, Schwachmann-Diamond), cholestatic liver disease, intestinal disease (celiac disease, Crohn's disease), increased energy needs (chronic condition, recurrent infections), endocrine problem (hypothyroidism, growth hormone deficiency)

37

In the absence of specific features, which of the following is not a common part of the initial testing of a child with growth failure based on history and physical?
a) bone age
b) TSH
c) CBC, ESR, CRP
d) serum protein, albumin

a) bone age - is step 2 (i get depending on if there are signs of puberty/advanced progression of growth)

first determine if there really is growth failure and what the intake is like, then based on the clinical picture, stepwise approach to investigations

step 1) (depending on clinical suspicion/picture) CBC, ESR, CRP, lutes, gas, glucose, BUN/Cr, protein/albumin, iron, TIBC, saturation, ferritin, Ca/Po4, ALP, AST, ALT, GGT, immunoglobulins, TTG (accompanied by total IgA level)
TSH, Urinalysis
step 2)Sweat chloride, Vitamin levels, Fecal elastase, Bone age

38

For an undernourished 15 month old who weighs 8 kg , what is the approximate caloric needs in cal/kg/day?
a) 80 cal/kg/day
b)90 cal/kg/day
c)100 cal/kg/day
d) 125 cal/kg/day

d) 125 cal/kg/day

Caloric needs (cal/kg/d) = caloric needs for weight age (cal/kg/d) × ideal weight for height (kg) / Actual weight (kg)

ways to increase calories - cream, oil, powdered milk or glucose polymers.can use age appropriate formulas that give 1 kcal/ml-1.5 kcal/ml

caloric needs: 0-1 year 90-120 kcal/kg/day. 1-7 years 75-90 kcal/kg/day

ideal weight 10 kg


39

Which of the following is not a first line approach to a child with growth failure?
a) calorie optimization
b) psychological support for behavioural concerns
c) reassurance for children that are growing consistent with their genetic potential
d) cyproheptadine

d) cyproheptadine only used occasionally, after expert consultation , in refractory cases
causes drowsiness, is an appetite stimulant, the benefit is it can make the kid like food again

appetite stimulants, such as cannabioid derivatives and megestrol acetate, have been used in some clinical situations but they should not be administered to healthy children [

tube feedings only a last resort

40

Which of the following is false about tube feedings for growth failure?
a)can increase oral aversion
b) can decrease appetite
c) easy to wean tube feedings
d) should be used in children where underlying disease is worsened by their poor nutritional status

c) hard to wean tube feedings

used in patients whose underlying disease is worsened by their poor nutritional status, jeopardizing outcome, or if oral intake is deemed unsafe.

use only as a last resort in otherwise normal children who are just having some trouble with weight gain

41

How many children with CP are overweight?
a) 65%
b) 30%
c) 20%
d) 8-14%

d) most children with CP are undernourished, 8-14% are overweight

42

Which of the following factors does not lead to more likelihood of poor nutrition in neurological impaired children?
a) more severe impairment
b) longer duration of impairment
c) presence of diplegia or hemiplegia vs spastic quad
d) oromotor dysfunction

c)
more malnutrition with more severe impairment and longer duration of impairment, spastic quad has most impairment but diplegia/hemiplegia also affected
oromotor dysfunction increases chance of needing tube feedings

43

Which of the following is not a cause of malnutrition in neurological impaired children?
a) decreased caloric needs in ambulatory children with hemiplegia
b) oromotor dysfunction
c) increased GERD and losses of food
d) decreased intake

a) false - in fact these children have increased caloric needs

the others:
- decreased intake, often takes them a long time to eat and so don't get to eat as much
- altered metabolism: resting energy expenditure in CP is generally lower than age matched controls , BUT for children who are ambulatory with hemiplegia/diplegia, they may use up more calories than other children , same with children with athetoid forms of CP
- increased losses - i.e. GERD/emesis
- promoter dysfunction - in 90% of children with CP, often have symptoms even before the diagnosis is made, prolonged mealtimes can't compensate for it

neurological status itself may affect growth independent of malnutrition - hemiplegia, paralyzed side is often smaller, other factors specific syndromes, endocrine dysfunction, ethnicity, genetic potential and pubertal status.

44

Which of the following is not a common presentation of aspiration?
a) desaturation during meals
b) progressive fatigue towards end of the meal
c) frank emesis
d) recurrent pneumonias
e) coughing and choking during meals
f) medications such as cyproheptadine
g) asymptomatic

f) false - this is an appetite stimulant
common medications that may decrease appetite in the neurologically abnormal child include topiramate and valproic acid

can get swallowing dysfunction relating to aspiration and also related to reflux (where they vomit then choke on food) both problems can overlap, watching a meal can be helpful
may be asymptomatic

45

Which of the following is the best method to detect malnutrition in neurological abnormal children (2 answers) ?
a) weight for height
b) triceps skinfold thickness
c) mid-arm circumference
d)subscapular skinfold thickness

b)and c) triceps skin fold thickness and mid-arm circumference may be more effective than weight for height to assess for malnutrition

Subscapular skinfold is often less affected than triceps skinfold in malnourished NI children [

overall, measure weight and height
weight: if can't stand, while held by parent or on wheelchair scale
height: supine if t stand, if have contractures/scoliosis, then leg length or arm span can be very helpful (with references)

exam all systems: resp (aspiration, clubbing), abdo +/- rectal exam (constipation), teeth (discomfort)

46

Which of the following is the best study to diagnose superior mesenteric artery syndrome?
a)swallowing study
b)upper GI
c) esophageal PH probe
d)gastric emptying

b) upper GI best to diagnose SMA syndrome:
- common in scoliosis and with rapid weight loss; full body cast
- chronic form with various GI complaints, acute can lead to significant obstruction and morbidity
- lateral or prone positioning are the treatment, need to feed them to get rid of the fat pad
the other tests:
- swallowing study helps determine promoter dysfunction/look for aspiration
- upper GI - good to look for anatomical abnormalities
- esophageal pH probe- whether aspiration is secondary to reflex
- gastric emptying study - look for delayed gastric emptying and possible pulmonary aspiration of gastric content

- usually don't need tons of bloodwork
can do a CBC to look for anemia
albumin not very useful in this population
lytes usually normal
Phosphorus, calcium, alkaline phosphatase and vitamin D can be considered +/- bone scan for suspected osteoporosis

47

Which of the following is false?
a) neurologically impaired children are more likely to have complications after anti-reflux surgery than other children
b) it is important to differentiate between aspiration of secretions and of gastric content
c) anticonvulsant medication lowers the risk of osteoporosis
d) most methods to determine needed calories for neurologically impaired children lead to overestimates

c) false - anticonvulsant medication can increase the risk of osteoporosis
other factors that may increase the risk of osteoporosis include:
educed ambulation and weight-bearing activity, malnutrition, limited sun exposure, decreased intake of supplements of Ca, vit D, phosphorus

48

Which of the following is the best method to ensure adequate intake in neurologically impaired children?
a) weight gain in response to dietary therapy
b) Krick method
c) Height based method
d) Ree based method

a) weight gain in response to dietary therapy is the best method

ways to calculate:
Krick method:Kcal/day = (BMR x muscle tone factor x activity factor) + growth factorBMR (kcal/day) = Body surface area (m2) x standard metabolic rate (kcal/m2/h) x 24h Muscle tone factor: 0.9 if decreased, 1.0 if normal, 1.1 if increased
Activity factor: 1.15 if bedridden, 1.2 if dependant, 1.25 if crawling, 1.3 if ambulatory
Growth factor: 5 kcal/g of desired weight gain
Height based:14.7 cal/cm in children without motor dysfunction 13.9 cal/cm in ambulatory patients with motor dysfunction11.1 cal/cm in non-ambulatory patients
Ree based method: 1.1 and measured resting energy expenditure

49

Which of the following is not a common complication of NG tubes?
a) sinusitis and congestion
b) otitis
c) local skin irritation
d) hard to dislodge

d) easy to dislodge is actually the issue

the other 3 are complications
should only use NG for short term nutrition less than 3 months) , if longer should consider gastrostomy
Oral intake can be maintained as long as there is no risk of aspiration, the child is growing well and the time required to feed the child remains within acceptable limits.
enteral feeds are if oral feeds are unsafe, too time consuming or not gaining enough weight with them

50

Which of the following is an appropriate indication of anti reflux surgery (in conjunction with gastrostomy) ?
a) all neurologically impaired children undergoing gastrostomy surgery
b) children who are found to have reflux not responding to medical therapy or with pulmonary aspiration undergoing gastrostomy surgery
c) prophylactic therapy for all children expected to be on gastrostomy feeds long terms
d) all children with recurrent aspiration pneumonia
e) as the next step in children who get symptoms of reflux after a gastrostomy

b) true, these children should have ARP

the other statements: not all NI children, high risk of complications from ARP in this populate

no role for prophylactic therapy
no all with aspiration pneumonia - hard to tell difference clinically between aspiration pulmonary and aspiration from reflex - in some cases may want to do a trial of NG feeds for one month to help see whether ARP might help
some kids get reflux as a result of gastrostomy, in these kids should ry treating with pro-kinetics, adjusting the volume and speed of the feeds before the ARP

**note, i think ARP means the same things as fundoplication

gastrostomy surgery can be done by open surgery, laparoscopic surgery, endoscopy (percutaneous endoscopic gastrostomy) or interventional radiology , percutaneous approach is for those who don't need ARP though (double check this with a surgeon)

51

Which of the following is false of gastro jejunal tubes?
a) larger caliber
b) more likely to get obstructed
c) should only be used long term in patients who are poor candidates for anti-reflux surgery
d) need to be repositioned with fluoroscopic guidance

a) false, in fact smaller calibre, more likely to get obstructed
Nasojejunal feeds should be used for short-term enteral nutrition in patients with gastroesophageal reflux or gastric dysmotility.
jejeunostomy may be an option in select cases
should always do continuous feeds when jejuna tube (remember you need the stomach to help pump out bolus feeds)

52

Which of the following is not a common consequence of using adult formulas in a neurological impaired child?
a) vitamin deficiency
b) inadequate calorie to nutrient ratio
c) hypercalcemia
d) phosphorus deficiency

c) in fact calcium deficiency is a consuence of using adult formulas

53

Which of the following is the appropriate formula to use for a 13 month old with constipation?
a) pediatric formula 1kcal/ml with fiber
b) infant formula 1kcal/ml with fiber
c) adult formula 1.5 kcal/ml with fiber
d) infant formula 1.5 kcal/ml with fiber

a) pediatric formula 1 kcal/ml with fiber

infant formula for

54

Which of the following is not an indication for continuous feeds?
a) ambulatory child with scheduled activities
b) gastro-jejeunal tubes
c) dumping syndrome
d) poor tolerance of gastric feeds

a) is not , for these guys bolus is more convenient

the other cases commonly need continuous feeds, and need continuous for all GJ tubes

should always do continuous feeds when jejuna tube (remember you need the stomach to help pump out bolus feeds)

55

What is the appropriate weight for height goal for a 8 year old child who is wheelchair bound but able to accomplish transfers?
a)10th percentile
b) 25th percentile
c) 50th percentile
d) >50th percentile

b 25th percentile for wheelchair bound but able to transfer, and older than 3 year old
for normal activity children and children younger than 3 50th percentile
for bedridden 10th percentile may be okay

always danger of overfeeding and excess weight gain with gastrostomy tubes, need to be careful to not have them gain too much weight because harder to transfer, also when NI children gain weight it is usually more fat than muscle (decreased lean weight)

ethics - should respect parents wishes, don't do it until they want to unless their are severe nutritional deficiencies or or child's health compromised