Growth And Development Flashcards
(347 cards)
1
Q
What are the defining criteria for Severe Acute Malnutrition (SAM)?
A
Presence of bilateral pitting edema (any grade), Visible severe wasting characterized by: MUAC < 115 mm in children 6-59 months, Weight-for-height (WFH) < −3 Z-scores
2
Q
What are the admission criteria for outpatient care in SAM?
A
The admission criteria for outpatient care and the discharge criteria from outpatient care in Severe Acute Malnutrition (SAM) are quite different, as they serve opposite purposes: one is used to determine if a child should begin outpatient care, and the other decides when they are stable enough to leave it.
Admission Criteria for Outpatient Care (SAM):
These are the conditions a child must meet to be admitted into outpatient care:
1. Bilateral pitting edema (Grade + or ++):
The child must show signs of severe malnutrition, indicated by swelling in both legs (edema), which is a hallmark of SAM.
2. Severe wasting (MUAC < 115 mm or WFH < -3 Z-scores):
The child is severely undernourished, with a MUAC of less than 115 mm or a weight-for-height (WFH) measurement lower than -3 Z-scores.
3. Pass the appetite test:
The child should be able to eat and tolerate therapeutic food, indicating they are not too weak to feed.
4. No medical complications, clinically well, and alert:
The child should not have serious medical conditions and must be in a stable, alert, and responsive state, which means they are not in need of intensive medical care.
3
Q
How is bilateral pitting edema classified in SAM?
A
+ Mild: Edema in both feet, ++ Moderate: Edema in both feet, lower legs, hands, or lower arms, +++ Severe: Generalized edema including feet, legs, hands, arms, and face.
4
Q
How is dermatosis classified in SAM?
A
+ Mild: Few rough patches or mild discoloration of the skin, ++ Moderate: Multiple patches on arms or legs, +++ Severe: Flaking skin, raw areas, or fissures.
5
Q
What are the clinical signs of vitamin A deficiency in SAM?
A
Eye infection: Pus and inflammation, Vitamin A deficiency signs: Corneal ulceration, Corneal clouding, Bitot’s spots.
6
Q
How is the appetite test performed, and what indicates a fail?
A
Procedure: The child is given Ready-to-Use Therapeutic Food (RUTF) and monitored for 30 minutes. Pass: Eats at least one-third of an RUTF packet (~30 g) within 30 minutes. Fail: Eats less than 30 g of RUTF in 30 minutes.
7
Q
What are the three phases of inpatient care for SAM management?
A
- Stabilization: Address life-threatening issues with medical care and cautious feeding. 2. Transition: Introduce therapeutic milk and small amounts of RUTF. 3. Rehabilitation: Full feeding with RUTF to achieve nutritional recovery.
8
Q
How is MUAC measured in children aged 6-59 months?
A
Mid-Upper Arm Circumference (MUAC) is measured in children aged 6-59 months by marking the midpoint between the shoulder and elbow, then wrapping a flexible tape around the upper arm at this point. A snug but not tight fit is required, and the measurement is recorded in centimeters. MUAC values help assess malnutrition: less than 11.5 cm indicates severe acute malnutrition (SAM), 11.5–12.4 cm indicates moderate acute malnutrition (MAM), and 12.5 cm or greater is normal.
9
Q
What are some examples of medical complications that necessitate inpatient care for SAM?
A
Intractable vomiting, Convulsions, Lethargy or unconsciousness, Hypoglycemia (<3 mmol/L), High fever (>38.5°C) or hypothermia (<35°C), Severe dehydration, Persistent diarrhea, Severe anemia, Lower respiratory tract infection, Eye signs of vitamin A deficiency, Dermatosis.
10
Q
How is a child’s weight-for-height (WFH) Z-score determined, and how should rounding be handled?
A
Locate the child’s height/length in the WFH Z-score table. Round length/height appropriately. Identify weight within the row under boys’ or girls’ columns. Z-score is listed at the top. If weight lies between Z-scores, report as < higher value.
11
Q
What is reductive adaptation in SAM, and why is it significant?
A
Reductive adaptation is metabolic downregulation during malnutrition to conserve energy. It ensures survival on limited intake but requires gradual nutrient reintroduction to prevent overwhelming compromised systems.
12
Q
How does reductive adaptation influence the clinical management of SAM?
A
Infection Management: Broad-spectrum antibiotics, avoid typical signs like fever. Iron Supplementation: Avoid early to prevent exacerbating infections. Cautious Feeding: Prevent refeeding syndrome by gradual calorie reintroduction.
13
Q
Why is the administration of antibiotics universally recommended for children with SAM?
A
Almost all children with SAM harbor latent or active bacterial infections, including pneumonia, urinary tract infections (UTIs), and otitis media. Due to reductive adaptation, the usual signs of infection (e.g., fever, inflammation) may be absent or muted. Broad-spectrum antibiotics are administered empirically to prevent complications. Specific antibiotics are added if an infection (e.g., Shigella or Giardia) is confirmed.
14
Q
Why should iron not be given early in SAM treatment, and what are the risks of free iron?
A
Iron supplementation is contraindicated in the early stabilization phase because: 1. Excess stored iron exists due to the body’s reduced hemoglobin synthesis during SAM. 2. Free iron can: Promote the formation of free radicals, causing oxidative stress and cellular damage. Exacerbate bacterial infections by creating an environment conducive to microbial growth. Divert energy needed for recovery processes toward ferritin synthesis to store excess free iron. Iron is administered only during the recovery phase when the child’s body begins to rebuild red blood cells and muscle tissue.
15
Q
What are the physiological dangers of rapid feeding or hydration in children with SAM?
A
Children with SAM undergoing reductive adaptation are at risk of refeeding syndrome if nutrients and fluids are reintroduced too quickly. Pathophysiology: Rapid feeding leads to a sudden insulin surge, causing electrolyte imbalances (e.g., hypokalemia, hypophosphatemia) and metabolic derangements. Clinical Implications: These shifts can result in cardiac failure, respiratory compromise, or death. Management involves: Low-volume, low-calorie feeding initially, with gradual increases over time. Careful monitoring of electrolytes and vital signs.
16
Q
When is iron supplementation appropriate during SAM treatment, and why is timing crucial?
A
Iron supplementation should be introduced in the recovery phase, once the child has stabilized and begun rebuilding tissue and red blood cells. During this phase, the body utilizes stored iron to meet the demands of hemoglobin and tissue synthesis. Early administration risks oxidative stress, exacerbation of infections, and unnecessary energy diversion.
17
Q
What infections are commonly associated with SAM, and how should they be addressed?
A
Common infections in SAM include: Pneumonia, Urinary tract infections (UTIs), Otitis media (ear infections), Gastrointestinal infections, such as Shigella or Giardiasis. Management involves: Empirical use of broad-spectrum antibiotics to cover bacterial pathogens. Adding targeted therapy if a specific infection is diagnosed.
18
Q
How should feeding be initiated in children with SAM?
A
Feeding begins with therapeutic milk (F-75), designed to provide energy and nutrients without overwhelming the child’s compromised metabolism. Once stabilized, the diet transitions to F-100 or Ready-to-Use Therapeutic Food (RUTF), with gradual caloric increases. Monitoring for signs of intolerance, such as vomiting or electrolyte imbalances, is essential.
19
Q
What are the three primary risks associated with free iron in children with SAM?
A
- Oxidative Stress: Free iron promotes free radical formation, leading to tissue damage. 2. Infection Exacerbation: Free iron supports bacterial growth, worsening systemic or localized infections. 3. Energy Diversion: Conversion of free iron to ferritin consumes energy and amino acids, delaying recovery processes.
20
Q
Why is correcting electrolyte imbalances critical in SAM?
A
Imbalances (low potassium, magnesium) lead to edema and impaired cell function. Supplement K (3–4 mmol/kg/day) and Mg (0.4–0.6 mmol/kg/day) as needed.
21
Q
Why should iron supplementation be delayed in SAM treatment?
A
Iron storage is often adequate in SAM, and early supplementation can cause oxidative damage and promote infection. Iron is given later when new red blood cell production starts.
22
Q
When should feeding be escalated to higher-calorie formulas?
A
Transition to F-100 or RUTF after stabilization to support weight recovery and tissue regeneration.
23
Q
What is the final step in the discharge process for a child with SAM?
A
Prepare the caregiver for outpatient follow-up or discharge if the child has fully recovered and is no longer at risk of refeeding complications.
24
Q
How should you monitor a child in shock?
A
Measure and record pulse and respiration rates every 10 minutes. This is crucial for tracking the child’s response to treatment.
25
What are the differences in signs for dehydration, septic shock, and both?
Dehydration: History of diarrhea, thirst, sunken eyes, reduced/absent urine flow. Septic shock: Hypothermia, weak/absent radial pulse, limb apathy, and cold extremities. Both: Lethargy or unconsciousness, slow capillary refill, weak or fast pulse.
26
What are the general guidelines for treating mild to moderate anaemia in severely malnourished children?
Mild to moderate anaemia can be treated with iron found in therapeutic feeds such as F-100 or RUTF. These provide adequate nutrition and iron without the need for immediate transfusion.
27
What is the initial feeding strategy for SAM?
Begin with F-75 therapeutic milk to stabilize the child’s condition, low in calories and protein to avoid overburdening the weakened system.
28
What are the primary causes of shock in severely malnourished children?
Shock in severely malnourished children is typically caused by dehydration and sepsis, which may coexist and are often difficult to differentiate.
29
What fluids are recommended for IV administration in severely malnourished children with shock?
Preferred fluids: Half-strength Darrow’s solution with 5% glucose, or Ringer’s lactate with 5% glucose. If neither is available, use half-normal saline (0.45%) with 5% glucose.
30
What are the key signs of severe anaemia in a malnourished child requiring blood transfusion?
A blood transfusion is required if: Hemoglobin (Hb) < 4 g/dl, Or respiratory distress with Hb between 4-6 g/dl. Clinical signs include extreme paleness of gums, lips, and inner eyelids.
31
What is the recommended protocol for blood transfusion in children with severe anaemia and SAM?
Whole blood: Administer 10 ml/kg body weight over 3 hours. Furosemide: Give 1 mg/kg IV at the start of the transfusion to prevent fluid overload. If signs of cardiac failure are present, use packed red blood cells (5-7 ml/kg) instead of whole blood.
32
How do you manage potential transfusion reactions during a blood transfusion?
Monitor for signs of transfusion reactions such as: Fever, itchy rash, dark red urine, confusion, or shock. If any of these occur, stop the transfusion immediately and seek immediate medical attention.
33
Why is fluid management crucial in treating shock in severely malnourished children?
Fluid management is critical to avoid overhydration, which can worsen edema and cardiac failure. The amount of fluids should be carefully monitored based on the child’s response.
34
When should you suspect heart failure in a severely anaemic child with SAM?
Heart failure should be suspected if the child has severe anaemia (Hb < 4 g/dl) and exhibits signs such as rapid breathing, swelling, or poor circulation. In such cases, transfuse packed red blood cells instead of whole blood.
35
What is the definition of hypoglycaemia in children with SAM?
Hypoglycaemia in children with SAM is defined as blood glucose < 3 mmol/L (or < 54 mg/dl). If glucose levels cannot be tested, assume all children with SAM are hypoglycaemic and treat accordingly.
36
How are hypoglycaemia and hypothermia related in children with SAM?
Hypoglycaemia and hypothermia often occur together and are signs of infection. Both conditions are dangerous and require immediate treatment.
37
How do you check for hypoglycaemia in a child with hypothermia?
Check for hypoglycaemia whenever hypothermia is present (axillary temperature < 35.0°C or rectal temperature < 35.5°C).
38
What is the treatment for hypoglycaemia in a conscious child with SAM?
For a conscious child: Administer glucose immediately (e.g., sucrose solution: 1 teaspoon sugar in 3 tablespoons water = 5g sucrose in 50 ml safe water). Monitor blood glucose after 30 minutes. If glucose is < 3 mmol/L, continue giving F-75 in small amounts every half hour for 2 hours.
39
What is the treatment for hypoglycaemia in an unconscious child with SAM?
1. Immediate Glucose Administration
Intravenous (IV) Route (if IV access is available):
Administer 10% dextrose solution at 5 mL/kg body weight as a bolus.
Nasogastric (NG) or Oral Route (if IV access is not available):
Administer 50 mL of 10% dextrose or sugar water solution via a nasogastric tube or orally, if the child is not vomiting.
2. Prevent Recurrence of Hypoglycemia
Once the child is stabilized, start frequent feeding:
Feed every 2-3 hours with therapeutic feeds, such as F-75 or a similar energy-dense formula.
If therapeutic feeds are not immediately available, use a locally prepared sugar-water solution.
3. Treat Underlying Causes
Look for and treat potential triggers, such as infections (e.g., sepsis, malaria, or pneumonia), which are common in children with SAM.
4. Monitor Blood Glucose
Check blood glucose levels every 30 minutes until stable, then monitor every few hours for at least 24 hours.
5. Transition to Routine SAM Management
Once stabilized, initiate the standard SAM management protocol, including continued feeding, micronutrient supplementation, and treatment of associated complications.
Note: Early identification of hypoglycemia and prompt treatment are critical to avoid complications such as brain damage or death.
40
What should you do if the child’s blood glucose does not rise above 3 mmol/L after 30 minutes?
Ensure the child has been given appropriate antibiotics and F-75. Continue feeding F-75 in small amounts (1/4 of the amount) every half hour for 2 hours.
41
How should you monitor a child with hypoglycaemia?
Monitor blood glucose levels every 30 minutes. Check rectal temperature regularly. If glucose levels still remain low after 2 hours, recheck the child’s condition and continue treatment.
42
How do you prevent hypoglycaemia in children with SAM?
Feed the child every 2 hours (day and night). Ensure feeds are given throughout the night. Rehydrate first if necessary before starting feeding.
43
How do you define hypothermia in children with SAM?
A child with SAM is considered hypothermic if their axillary temperature is < 35.0°C or rectal temperature < 35.5°C.
44
What is the initial treatment for hypothermia in a child with SAM?
1. Rewarm the child: Dress the child in warm clothing (including the head). Cover with a warmed blanket. Use a heater or lamp to warm the room (avoid hot water bottles). Place the child on the mother’s bare chest (skin-to-skin) for warmth. 2. Administer appropriate antibiotics. 3. Give glucose and feed immediately.
45
How do you monitor a child during rewarming for hypothermia?
Check the rectal temperature every 2 hours during rewarming. If using a heater, check every half hour. Ensure the child is covered at all times, especially at night. Feel for warmth to ensure they are rewarming appropriately.
46
What are some preventative measures to avoid hypothermia in children with SAM?
Feed the child every 2 hours (day and night). Keep the child covered and dry (change wet clothes, nappies, and bedding). Avoid exposing the child to cold environments (e.g., prolonged medical exams, bathing). Ensure the child sleeps with the mother/carer for warmth at night.
47
What should you do if you don't have a thermometer to measure the child's temperature?
If the thermometer can't register the child’s temperature due to it being too low, assume the child is hypothermic and begin immediate rewarming and treatment.
48
What is the first intervention for a child with SAM?
Prevent or treat hypoglycemia by administering glucose immediately, as hypoglycemia is common in SAM.
49
How is hypothermia managed in children with SAM?
Gradual warming with warm blankets and monitoring of body temperature. Avoid rapid warming to prevent complications.
50
What is the key treatment for dehydration in SAM?
Oral rehydration with ReSoMal (a low-sodium solution) and careful monitoring of fluid intake to prevent overload.
51
Why should infections always be treated aggressively in SAM?
SAM-induced reductive adaptation impairs the immune response. Treat all with broad-spectrum antibiotics (e.g., ceftriaxone) and adjust if specific infection is identified.
52
How is emotional and sensory development addressed in SAM?
Encourage stimulation through play and affectionate care to foster development, improving psychological recovery.
53
How can you differentiate between dehydration and septic shock in severely malnourished children?
Dehydration responds to IV fluids. Septic shock without dehydration does not respond to fluids. Key indicators for shock include: cold hands, slow capillary refill, and a weak or fast pulse.
54
What are the signs of shock in a severely malnourished child?
A child with shock is lethargic or unconscious and has cold hands, plus either: Slow capillary refill (more than 3 seconds), or Weak or fast pulse.
55
Can a child with SAM have dehydration even if they have oedema?
Yes, even with oedema, a child with SAM may still be dehydrated. Oedema indicates fluid distribution problems, not necessarily an excess of fluid in the body.
56
What should be done for rehydration in children with SAM?
ReSoMal is the solution used for rehydration in malnourished children. Avoid using IV fluids unless the child is in shock. If IV fluids are necessary, infuse slowly to prevent overloading the heart.
57
How do you assess dehydration in children with SAM?
Signs of dehydration are difficult to assess in SAM children because common signs (e.g., sunken eyes, lethargy) may always be present. Ask the mother about recent symptoms like watery diarrhoea, vomiting, or changes in the child’s condition (e.g., decreased urine output).
58
What are signs that rehydration is improving?
Respiratory and pulse rates slow down. Child begins to pass urine, feels less thirsty, and skin pinch response improves. Less lethargy and improvement in other hydration signs like moist mouth, and improved skin turgor.
59
What are the signs of overhydration during rehydration?
Increased respiratory rate and pulse rate (both must rise to indicate a problem). Engorged jugular veins (pulse visible in the neck). Increasing oedema, such as puffy eyelids.
60
What should you do if signs of overhydration appear?
Stop ReSoMal immediately if signs of overhydration are present. Reassess after 1 hour.
61
When should you not use ReSoMal?
Do not use ReSoMal if the child is suspected to have cholera or is experiencing profuse watery diarrhoea. In such cases, use low osmolarity oral rehydration solution (ORS).
62
What is the correct oral rehydration solution for children with SAM?
Use ReSoMal (Rehydration Solution for Malnutrition) instead of standard ORS. Standard ORS contains too much sodium and too little potassium for severely malnourished children.
63
What should you do if signs of coexisting infection or overhydration are observed?
Stop fluids immediately if rapid breathing and rising pulse rate continue during rehydration. Reassess after 1 hour to determine if the child is improving.
64
How should you prevent dehydration in children with continuing watery diarrhoea?
Continue feeding with F-75. Replace stool losses with ReSoMal: 15-30 ml/kg after each loose stool for severely wasted children. 30 ml per loose stool for children with oedema.
65
Should small, unformed stools be treated the same as watery diarrhoea?
No, small unformed stools common in malnourished children do not require fluid replacement. Only profuse watery diarrhoea requires fluid replacement.
66
What if the child is breastfed?
Encourage the mother to continue breastfeeding as it helps with hydration and nutrition.
67
What electrolyte imbalances are commonly observed in children with Severe Acute Malnutrition (SAM)?
In children with SAM, common electrolyte imbalances include:
Sodium: Children may have excess sodium despite low plasma sodium levels.
Potassium and Magnesium Deficiencies: These deficiencies are common and can take up to 2 weeks to correct.
Oedema: Caused by electrolyte imbalances, particularly deficiencies in potassium and magnesium, and will resolve with appropriate therapeutic feeding.
68
How should electrolyte imbalances in SAM be managed?
Do not administer diuretics for oedema, as they worsen the imbalance and could be fatal. Use low sodium, high potassium rehydration fluids (e.g., ReSoMal) for rehydration. Correct imbalances through therapeutic feeding with F75, F100, or RUTF.
69
What is the approach to infection management in severely malnourished children on admission?
Broad-spectrum antibiotics should be administered routinely to cover potential infections. Measles vaccination should be given if the child is over 6 months and has not been immunized (delayed if the child is in shock). Metronidazole (7.5 mg/kg every 8 hours for 7 days) is often used to support intestinal mucosal healing and reduce the risk of anaerobic bacterial overgrowth.
70
When should iron supplementation be initiated in children with SAM?
Iron therapy should be avoided initially, as it can exacerbate infections. It should only be given once the child shows a good appetite and begins to gain weight. Iron should not be given to children on RUTF, as it may interfere with recovery.
71
How should folic acid and vitamin A supplementation be managed in children with SAM?
Folic Acid: Administer a single dose of 5 mg on Day 1. Additional folic acid is only needed if CMV is not used in F-75 and F-100 preparation.
Vitamin A: Give a single high dose on admission if there are signs of vitamin A deficiency, persistent diarrhoea, measles, or if the child is HIV-positive. Avoid giving Vitamin A in children with severe oedema.
72
What is the feeding protocol for severely malnourished children in the stabilization phase?
Start feeding as soon as possible with F75 (avoid F100 initially to prevent refeeding syndrome). Begin with small, frequent feeds (every 2 hours, 12 feeds/day). In hypoglycaemia, give one-quarter of the feed every 30 minutes until blood glucose is above 3mmol/L. On Day 2, transition to 3-hourly feeds if vomiting and diarrhoea improve.
73
How should transition to RUTF or F100 be managed once stabilization is achieved?
RUTF or F100 should be introduced once appetite returns, oedema resolves, and the child is clinically stable. Gradually increase RUTF intake by 10 ml per feed every 2 days. If a child does not take at least 75% of RUTF in the first 12 hours, continue with F75 and reintroduce RUTF after 1-2 days.
74
Under what circumstances should nasogastric tube (NGT) feeding be initiated in SAM management?
NGT feeding is recommended if the child fails to take 80% of the prescribed feed orally over 2-3 consecutive feeds. The NGT should be removed once the child consistently consumes 81% of the daily feed orally or completes two consecutive feeds by mouth.
75
What key factors should be monitored and documented during the stabilization phase of treatment for SAM?
Monitor feeding intake (amount offered vs. amount consumed), vomiting, diarrhoea, and weight. Record feeding data on the 24-Hour Food Intake Chart and in the Inpatient Management Record. Track changes in oedema and document any changes in the child’s clinical status, such as improved appetite or reduced signs of infection.
76
What are the discharge criteria for children with SAM from outpatient care?
Discharge Criteria from Outpatient Care (SAM):
These are the conditions a child must meet to be considered for discharge from outpatient care:
1. MUAC > 125 mm and weight-for-height > -2 Z-scores for 2 consecutive weeks:
1. The child’s nutritional status must be stable, with the MUAC above 125 mm and weight-for-height above -2 Z-scores for two weeks.
1. 15% weight gain maintained for 2 weeks:
1. The child should have gained at least 15% of their body weight and maintained this for two weeks.
1. Clinically well, alert, and oedema-free for 2 weeks:
1. The child must be free of oedema, be alert, and show no clinical signs of illness for at least two weeks.
1. Stable for continued outpatient care:
1. The child should be stable enough to continue recovery outside of intensive care, allowing for outpatient follow-up.
1. Key Differences:
1. Admission criteria focus on identifying severe malnutrition and the need for treatment, such as severe wasting, edema, and the ability to feed.
1. Discharge criteria focus on recovery and stability, ensuring the child is nutritionally stable, gaining weight, and free from complications before being allowed to leave outpatient care.
1. In short, the admission criteria are for starting treatment, and the discharge criteria are for ensuring the child has improved enough to continue recovery independently.
77
How should diarrhoea be managed in children with SAM who also have diarrhoea?
RUTF, F75, and F100 can be administered even in the presence of diarrhoea. Do not mix RUTF or therapeutic milk with water to avoid bacterial contamination. Monitor closely for any signs of worsening diarrhoea or dehydration and adjust feeding accordingly.
78
How is Appetite Testing with RUTF performed and what are the criteria for success?
Appetite Test: Offer the child one-third of a packet of RUTF (92 g) and observe if the child finishes it within 30 minutes.
Pass Criteria: The child consumes at least one-third of the RUTF packet within 30 minutes.
Fail Criteria: The child does not consume one-third of the RUTF packet within 30 minutes.
79
What is the first step in transitioning from the starter formula (F-75) to the catch-up formula (RUTF or F100)?
The first step is to replace starter F-75 with either RUTF or F100 for 48 hours, then gradually increase feed volume by 10 ml until some feed remains uneaten.
80
How should you monitor a child during the transition to the catch-up formula (RUTF or F100)?
Monitor for heart failure by checking respiratory rate and pulse every 4 hours. Reduce feed volume if respiratory rate increases by 5 breaths/min and pulse by 25 beats/min for two successive readings.
81
What feeding targets should be followed after the transition to catch-up formula (RUTF or F100)?
Provide frequent feeds (at least every 4 hours) of unlimited amounts of catch-up formula, ensuring 150-220 kcal/kg/day and 4-6 g protein/kg/day.
82
How should you assess the child's progress after transitioning to the catch-up formula?
Monitor weight daily before feeding. Calculate weight gain as g/kg/day. Assess weight gain rates: <5 g/kg/day (poor), 5-10 g/kg/day (moderate), >10 g/kg/day (good).
83
What is the recommended treatment for Vitamin A deficiency in children with severe malnutrition?
For children >12 months: 200,000 IU orally; 6-12 months: 100,000 IU orally; <6 months: 50,000 IU orally. Treat corneal issues with eye drops, saline eye pads, and bandaging.
84
What are the signs of severe dermatosis in a malnourished child, and how should it be treated?
Signs include hypo/hyperpigmentation, desquamation, ulceration, and exudative lesions. Treat with daily bathing, barrier creams, and antibiotics/antifungals if needed.
85
When should deworming medication be given to a malnourished child, and what medications are used?
Administer after 1 week on catch-up formula or earlier if needed. Use Albendazole (200 mg for ages 1-2, 400 mg for >2 years) or Mebendazole (300 mg for ages 1-2, 600 mg for >2 years).
86
How is diarrhea managed in children with severe malnutrition?
Consider giardiasis (treat with Metronidazole) or lactose intolerance (substitute milk with yogurt). Gradually reintroduce milk feeds and manage osmotic diarrhea by introducing F-100.
87
How should tuberculosis (TB) be treated in children with severe malnutrition?
Suspect TB with chronic cough or poor growth despite good intake. Confirm with chest X-ray or tests and treat according to national TB guidelines.
88
How should children with severe malnutrition and HIV be managed?
Follow SAM treatment protocols. Start antiretroviral therapy (ART) after stabilizing complications and sepsis.
89
Why should diuretics not be used in the treatment of oedema in children with SAM?
Oedema in SAM is due to potassium and magnesium deficiencies. Diuretics worsen electrolyte imbalance and delay recovery.
90
Why should high-protein formulas be avoided in the initial days of SAM treatment?
High-protein formulas can overload the liver, heart, and kidneys, causing complications or death. Use appropriate formulations like F-75.
91
When should intravenous (IV) fluids be administered to a child with SAM?
Administer IV fluids only for signs of shock. Avoid unless necessary to prevent fluid overload and heart failure.
92
When should vitamin A be administered to a child with SAM?
Administer only if there are visible signs of vitamin A deficiency, measles, severe diarrhea, or HIV. Provide a single high dose.
93
What should be used instead of ORS in the treatment of SAM?
Use ReSoMal instead of ORS as it is better suited for children with severe malnutrition.
94
How should SAM in infants under 6 months of age be managed?
Provide F-100-Diluted or infant formula until they are old enough for complementary foods. For oedema, start with F-75.
95
When should an infant with SAM under 6 months be discharged?
Discharge when gaining 20 g/day on breast milk alone for 2-3 days, or after ensuring breastfeeding adequacy and weight gain.
96
What is the supplementary suckling technique, and when is it used?
It stimulates breast milk production by allowing the infant to suckle while receiving F-100-Diluted from a cup placed below the nipple.
97
Describe the growth phase primarily affected in a 3-month-old infant diagnosed with intrauterine growth restriction (IUGR) and its long-term implications.
Affected Phase: Fetal growth phase (dependent on placental function and maternal health). Long-term Implications: Increased risk of metabolic syndrome, short stature, and cognitive delays.
98
Explain the role of thyroid hormone in childhood growth and the consequences of its deficiency.
Role: Stimulates bone growth, brain development, and metabolism. Deficiency Consequences: Growth retardation, intellectual disability (if congenital hypothyroidism is untreated), and delayed bone age.
99
How does early puberty in a 14-year-old girl affect her final adult height?
Early puberty leads to early epiphyseal fusion, reducing adult height potential despite an initial growth spurt.
100
Calculate the expected weight for a 7-year-old child using the appropriate formula.
Use the formula (Age × 2) + 8. For a 7-year-old: (7 × 2) + 8 = 22 kg.
101
Identify three causes of failure to thrive (FTT).
1. Inadequate intake (poor feeding, neglect, food insecurity). 2. Malabsorption (celiac disease, cystic fibrosis). 3. Increased energy demand (congenital heart disease, hyperthyroidism).
102
What conditions should be considered for an 8-month-old who has not tripled their birth weight?
Malnutrition (protein-energy malnutrition), chronic infections (tuberculosis, HIV), congenital conditions (hypothyroidism, growth hormone deficiency).
103
Assess the concern for a 6-month-old with an occipitofrontal circumference (OFC) of 39 cm.
The expected OFC at 6 months is 43 cm. Causes of Microcephaly: Congenital infections (TORCH), perinatal asphyxia, genetic syndromes.
104
What conditions should be considered for a child with an enlarged anterior fontanelle at 18 months?
Rickets (vitamin D deficiency), hypothyroidism, hydrocephalus.
105
Diagnose a 2-year-old with an MUAC of 11 cm and state the next step in management.
Diagnosis: Severe acute malnutrition (SAM). Next step: Start ReSoMal for rehydration, followed by F-75 feeding.
106
Differentiate between the clinical signs of kwashiorkor and marasmus.
Kwashiorkor: Edema, moon face, hepatomegaly, hypoalbuminemia. Marasmus: Severe muscle wasting, no edema, skin wrinkling.
107
Identify the causes and dietary management for a 3-year-old child with iron deficiency anemia.
Causes: Late weaning, excessive cow’s milk, poor dietary intake. Dietary Management: Increase iron-rich foods (meat, eggs, legumes) and give oral iron supplements with vitamin C for absorption.
108
What is the likely deficiency in a 6-month-old exclusively breastfed infant presenting with delayed milestones and lethargy?
Vitamin B12 deficiency (common in infants of vegan mothers).
109
Outline the treatment for a 4-year-old diagnosed with vitamin A deficiency presenting with night blindness and Bitot spots.
Mild cases: Vitamin A supplementation. Severe cases: WHO protocol with high-dose vitamin A (200,000 IU for children over 1 year).
110
Describe the advantages of using ReSoMal over ORS in managing severe malnutrition.
ReSoMal has less sodium and more potassium, which helps prevent re-feeding syndrome and excessive sodium load.
111
Define the caloric composition of F-75 and F-100 used in malnutrition management.
F-75 contains 75 kcal/100 mL and is used in the stabilization phase, while F-100 contains 100 kcal/100 mL and is used in the rehabilitation phase.
112
How should a child with SAM and hypoglycemia presenting with lethargy be treated initially?
The first step is to give 10% dextrose or breast milk immediately and maintain feeding every 2 hours to prevent further hypoglycemia.
113
Identify the likely diagnosis and cause for a child with bowing of legs and frontal bossing.
Diagnosis: Rickets. Cause: Vitamin D deficiency due to lack of sun exposure or exclusive breastfeeding without supplementation.
114
What are the classic X-ray findings associated with rickets?
Classic findings include widened metaphyses, cupping and fraying of bone ends, and Looser’s zones (pseudo-fractures).
115
List three possible complications for a 12-year-old with a BMI in the 99th percentile.
1. Type 2 diabetes. 2. Hypertension. 3. Slipped capital femoral epiphysis (SCFE).
116
What is the best screening test for insulin resistance in an obese child?
Fasting insulin and HOMA-IR (Homeostatic Model Assessment of Insulin Resistance).
117
Explain the difference between foremilk and hindmilk in breastfeeding.
Foremilk is watery and rich in lactose, found in the initial part of feeding, while hindmilk is fat-rich and high in calories, found in the later part of feeding.
118
Should a mother be concerned if her 2-month-old exclusively breastfed infant has loose, yellow stools?
No, breastfed stools are naturally loose and yellow due to high lactose content.
119
At what age should iron-rich complementary foods be introduced to infants?
Iron-rich complementary foods should be introduced at 6 months to prevent iron deficiency.
120
What is the likely diagnosis and treatment for a 9-month-old with generalized edema and skin peeling?
Diagnosis: Kwashiorkor. Treatment: Stepwise refeeding with F-75, then F-100 and micronutrient supplementation.
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What endocrine disorder should be suspected in a 10-year-old with short stature and central obesity?
Cushing syndrome or hypothyroidism.
122
Summarize the '5 Ws of Rickets' mnemonic.
The '5 Ws of Rickets' include Wrapping, Winter, Windows (lack of sun), Weaning delay, and Wrong diet.
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What does the mnemonic 'M for Marasmus' signify?
M for Marasmus signifies Muscle wasting.
124
What does the mnemonic 'ABC' represent in Vitamin A Deficiency?
Vitamin A Deficiency = 'ABC' → Alopecia, Bitot spots, Corneal ulcers.
125
Identify the growth phase affected in a 3-month-old diagnosed with intrauterine growth restriction (IUGR).
The affected phase is the fetal growth phase, which is dependent on placental function and maternal health.
126
What are the long-term implications of intrauterine growth restriction (IUGR)?
Long-term implications include increased risk of metabolic syndrome, short stature, and cognitive delays.
127
Describe the role of thyroid hormone in childhood growth and the consequences of its deficiency.
Thyroid hormone stimulates bone growth, brain development, and metabolism. Deficiency can lead to growth retardation, intellectual disability (if congenital hypothyroidism is untreated), and delayed bone age.
128
Describe how early puberty can affect a girl's final adult height.
Early puberty leads to early epiphyseal fusion, which reduces adult height potential despite an initial growth spurt.
129
Define the formula to calculate the expected weight for a 7-year-old child.
The expected weight is calculated using the formula (Age × 2) + 8. For a 7-year-old: (7 × 2) + 8 = 22 kg.
130
List three causes of failure to thrive (FTT).
1. Inadequate intake (poor feeding, neglect, food insecurity). 2. Malabsorption (celiac disease, cystic fibrosis). 3. Increased energy demand (congenital heart disease, hyperthyroidism).
131
Identify conditions to consider if an 8-month-old has not tripled their birth weight.
Consider malnutrition (protein-energy malnutrition), chronic infections (tuberculosis, HIV), and congenital conditions (hypothyroidism, growth hormone deficiency).
132
Explain the concern for a 6-month-old with an occipitofrontal circumference (OFC) of 39 cm.
The expected OFC at 6 months is 43 cm, indicating potential microcephaly.
133
Determine the diagnosis and next step for a 2-year-old with an MUAC of 11 cm.
Diagnosis: Severe acute malnutrition (SAM). Next step: Start ReSoMal for rehydration, followed by F-75 feeding.
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Differentiate between kwashiorkor and marasmus based on clinical signs.
Kwashiorkor: Edema, moon face, hepatomegaly, hypoalbuminemia. Marasmus: Severe muscle wasting, no edema, skin wrinkling.
135
Identify the causes and dietary management for a 3-year-old with iron deficiency anemia.
Causes: Late weaning, excessive cow’s milk, poor dietary intake. Dietary Management: Increase iron-rich foods and give oral iron supplements with vitamin C for absorption.
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What deficiency is likely in a 6-month-old exclusively breastfed infant with delayed milestones and lethargy?
Vitamin B12 deficiency, common in infants of vegan mothers.
137
Outline the treatment for a 4-year-old diagnosed with vitamin A deficiency.
Mild cases: Vitamin A supplementation. Severe cases: WHO protocol with high-dose vitamin A (200,000 IU for children over 1 year).
138
Explain why ReSoMal is preferred over ORS in cases of severe malnutrition.
ReSoMal has less sodium and more potassium, preventing re-feeding syndrome and excessive sodium load.
139
What is the caloric composition of F-75 and F-100 formulas?
F-75: 75 kcal/100 mL, used in the stabilization phase. F-100: 100 kcal/100 mL, used in the rehabilitation phase.
140
What is the first step for a child with SAM and hypoglycemia presenting with lethargy?
Give 10% dextrose or breast milk immediately and maintain feeding every 2 hours to prevent further hypoglycemia.
141
Identify the diagnosis and cause for a child with bowing of legs, frontal bossing, and delayed fontanelle closure.
Diagnosis: Rickets. Cause: Vitamin D deficiency (lack of sun exposure, exclusive breastfeeding without supplementation).
142
Describe the classic X-ray findings in rickets.
Widened metaphyses, cupping and fraying of bone ends, and Looser’s zones (pseudo-fractures).
143
Identify three possible complications for a 12-year-old with a BMI in the 99th percentile.
Type 2 diabetes, hypertension, and slipped capital femoral epiphysis (SCFE).
144
Define the best screening test for insulin resistance in an obese child.
Fasting insulin and HOMA-IR (Homeostatic Model Assessment of Insulin Resistance).
145
Assess whether a mother should be concerned about her 2-month-old exclusively breastfed infant's loose, yellow stools.
No, breastfed stools are naturally loose and yellow due to high lactose content.
146
Diagnose and suggest treatment for a 9-month-old with generalized edema, skin peeling, and apathy.
Diagnosis: Kwashiorkor. Treatment: Stepwise refeeding with F-75, then F-100 and micronutrient supplementation.
147
Identify the endocrine disorder suspected in a 10-year-old with short stature, delayed puberty, and central obesity.
Cushing syndrome or hypothyroidism.
148
What does 'M for Marasmus' signify in terms of malnutrition?
Muscle wasting.
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What does 'K for Kwashiorkor' represent in the context of malnutrition?
Kapok (swelling).
150
List the signs of Vitamin A Deficiency using the mnemonic 'ABC'.
Alopecia, Bitot spots, Corneal ulcers.
151
Identify the most important differential diagnoses for a 6-year-old child with a height below the 3rd percentile.
Familial short stature, constitutional growth delay, chronic disease (e.g., celiac disease, cystic fibrosis), and endocrine disorders (GH deficiency, hypothyroidism).
152
How do you calculate mid-parental height (MPH) for boys?
Boys = [(father’s height + mother’s height) / 2] + 6.5 cm.
153
How do you calculate mid-parental height (MPH) for girls?
Girls = [(father’s height + mother’s height) / 2] − 6.5 cm.
154
What is the immediate management for a 2-year-old with weight-for-height <−3 SD, lethargy, hypoglycemia, and hypotonia?
Step 1: Correct hypoglycemia (10% dextrose bolus). Step 2: Prevent hypothermia (keep warm). Step 3: Start ReSoMal if dehydrated (avoid regular ORS). Step 4: Begin F-75 feeding (low protein, low sodium).
155
Differentiate between marasmus and failure to thrive (FTT).
Marasmus: Severe wasting, muscle atrophy, no edema. FTT: Underweight, but with some subcutaneous fat retained.
156
What lab test confirms the suspected diagnosis for a 10-month-old with bilateral pitting edema and hepatomegaly?
Serum albumin → Low in kwashiorkor (<3.5 g/dL).
157
Interpret a z-score of −2.8 SD for height in a 4-year-old.
Indicates moderate chronic malnutrition (stunting).
158
What is the best single measurement for acute malnutrition?
Weight-for-height.
159
Define Mid-upper arm circumference (MUAC) and its significance in malnutrition assessment.
MUAC is a measurement used to assess nutritional status, with severe malnutrition indicated by MUAC <11.5 cm and moderate malnutrition by MUAC 11.5–12.5 cm.
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Describe the physical sign that distinguishes congenital hypothyroidism from nutritional stunting.
Delayed bone age with a large anterior fontanelle is indicative of congenital hypothyroidism.
161
Identify the suspected deficiency in a 3-year-old with bowed legs, frontal bossing, and widening of wrists.
The suspected deficiency is Vitamin D, indicating rickets, confirmed by low calcium and phosphate, and high alkaline phosphatase and PTH.
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What vitamin deficiency is indicated by angular cheilitis, glossitis, and photophobia in a child?
Vitamin B2 (riboflavin) deficiency is indicated.
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Explain the symptoms and suspected deficiency in a 7-year-old with ataxia, muscle weakness, and absent deep tendon reflexes.
These symptoms suggest Vitamin E deficiency, which is common in fat malabsorption disorders.
164
How does ReSoMal differ from standard ORS in treating severe malnutrition?
ReSoMal has lower sodium to prevent hypernatremia, higher potassium to replace losses, and contains glucose and micronutrients to correct deficiencies.
165
What complication can arise from using standard ORS in a severely dehydrated malnourished child?
Excess sodium in standard ORS can lead to fluid retention and worsening kwashiorkor.
166
Identify the likely cause of blood-streaked stools in an exclusively breastfed infant.
The likely cause is cow’s milk protein allergy due to maternal dairy intake.
167
List two absolute contraindications to breastfeeding.
1. Galactosemia (baby cannot metabolize lactose). 2. HIV in high-resource settings (due to risk of transmission).
168
What food should be avoided before 1 year to prevent infant botulism?
Honey should be avoided before 1 year due to the risk of infant botulism.
169
Describe the underlying condition in a 13-year-old with a BMI >99th percentile and acanthosis nigricans.
The likely underlying condition is insulin resistance, which can indicate early type 2 diabetes.
170
What is the likely diagnosis for a 10-year-old with obesity presenting with a painful limp?
The likely diagnosis is Slipped Capital Femoral Epiphysis (SCFE).
171
What is the most likely diagnosis for a 6-month-old exclusively breastfed infant with seizures and irritability?
The most likely diagnosis is hypocalcemia due to vitamin D deficiency (rickets).
172
What is the next best test for a 5-year-old with spoon-shaped nails, pica, and fatigue?
The next best test is serum ferritin and CBC to evaluate for iron deficiency anemia.
173
Identify the diagnosis for a 9-month-old fed only rice porridge who has generalized edema and a moon face.
The diagnosis is kwashiorkor (protein-energy malnutrition).
174
What are the key symptoms of Vitamin A deficiency?
Key symptoms include alopecia, Bitot spots, and corneal ulcers.
175
Differentiate between Marasmus and Kwashiorkor using a mnemonic.
Marasmus is associated with muscle wasting (M), while Kwashiorkor is associated with kapok-like swelling (K).
176
List the risk factors for rickets using the 5Ws mnemonic.
Risk factors include Wrapping (excessive clothing), Winter (less sun exposure), Windows (staying indoors), Weaning delay (prolonged exclusive breastfeeding), and Wrong diet (low vitamin D, calcium, phosphate).
177
What is the initial step in managing a 2-year-old with severe wasting and edema starting nutrition therapy?
The initial step is to carefully monitor and manage refeeding syndrome during the initiation of nutrition therapy.
178
Describe the symptoms that develop on day 3 of refeeding syndrome.
Tachycardia, muscle weakness, and hyporeflexia.
179
Define refeeding syndrome and its likely cause.
Refeeding syndrome is a sudden shift in electrolytes after nutrition, caused by rapid glucose metabolism leading to increased insulin and resulting in hypophosphatemia, hypokalemia, and hypomagnesemia.
180
How should electrolytes be managed in a patient at risk for refeeding syndrome?
Monitor electrolytes (PO4, K+, Mg2+) and provide phosphate supplements if levels are below 1.5 mg/dL.
181
Explain the difference in edema presentation between kwashiorkor and marasmus.
Kwashiorkor causes edema due to severe protein deficiency leading to low albumin and reduced oncotic pressure, while marasmus involves caloric and protein deficiency but less hypoalbuminemia, resulting in no edema.
182
What is the reason for delaying iron supplementation in cases of severe malnutrition?
Iron supplementation too early can increase free radicals and worsen infections; it should be started after 2 weeks when the child stabilizes.
183
Identify the suspected electrolyte abnormality in a child with kwashiorkor who has irritability and muscle cramps.
Hypokalemia.
184
How is hypoglycemia managed in malnourished children?
Administer 10% dextrose IV if symptomatic.
185
What immediate action should be taken for a newborn diagnosed with galactosemia?
Eliminate lactose and galactose from the diet and switch to soy formula.
186
Define the condition associated with musty-smelling urine in a child with developmental delay.
Phenylketonuria (PKU), caused by a deficiency in phenylalanine hydroxylase.
187
What is the recommended treatment for a child with phenylketonuria?
A low-phenylalanine diet, avoiding meat, dairy, and aspartame.
188
What diagnosis is indicated by delayed walking and leg bowing in a child with a low dairy diet?
Rickets, which is caused by Vitamin D deficiency.
189
Identify the vitamin deficiency in a 12-year-old with night blindness and Bitot spots.
Vitamin A deficiency.
190
What is the treatment for Vitamin C deficiency, also known as scurvy?
Oral vitamin C.
191
List the key benefits of breastfeeding compared to formula feeding.
Breast milk provides more IgA for passive immunity, better fat digestion, improved iron absorption, and reduces the risk of SIDS.
192
What is the main risk associated with exclusive formula feeding?
Increased risk of infections such as diarrhea, otitis media, and pneumonia.
193
How should a 7-month-old who refuses solid foods be encouraged to eat?
Introduce soft foods slowly, encourage self-feeding with finger foods, and avoid force-feeding to prevent aversion.
194
What is the most important first food to prevent iron deficiency anemia in infants?
Iron-fortified cereals or pureed meats.
195
Describe the dietary sources recommended for iron supplementation.
Iron-fortified cereals or mashed meat.
196
Identify the endocrine disorder to rule out in a 14-year-old with obesity, short stature, and delayed puberty.
Hypothyroidism.
197
How can hypothyroidism be confirmed in a patient?
By measuring TSH and free T4 levels.
198
What condition is indicated by truncal obesity, moon face, and hypertension in a child?
Cushing’s syndrome (excess cortisol).
199
Define the 6 F’s of obesity in children.
1. Food (excess calorie intake), 2. Family history (genetic predisposition), 3. Fat metabolism (metabolic syndromes), 4. Fructose intake (high sugar diet), 5. Fitness lack (physical inactivity), 6. Fat hormones (hypothyroidism, Cushing’s).
200
List the vitamin deficiency associated with Beriberi and Wernicke’s encephalopathy.
Vitamin B1 (Thiamine).
201
What are the symptoms of Vitamin B3 deficiency?
Pellagra, characterized by the 3 D’s: Dermatitis, Diarrhea, Dementia.
202
Explain why standard ORS is not recommended for severely malnourished children.
Standard ORS has high sodium (90 mmol/L), which poses a risk of hypernatremia and heart failure, and does not replace low potassium and magnesium levels in malnourished children.
203
What is ReSoMal and how does it differ from standard ORS?
ReSoMal (Rehydration Solution for Malnutrition) is designed for severely malnourished children, with lower sodium (45 mmol/L), higher potassium and magnesium, and includes glucose and minerals to prevent hypoglycemia.
204
When should ReSoMal be used instead of ORS?
ReSoMal should be used for severe malnutrition with dehydration, especially with severe edema and low potassium.
205
What is the pharmacological treatment for a child with severe vitamin D deficiency presenting with rickets?
High-dose Vitamin D (50,000 IU per day for 2–3 weeks) and calcium supplementation (Calcium carbonate or calcium citrate), with monitoring of calcium and phosphorus levels.
206
What is the recommended treatment for severe iron deficiency anemia in a 2-year-old with a hemoglobin of 5 g/dL?
IV iron (e.g., iron sucrose or ferric gluconate) if unable to tolerate oral, or oral iron supplementation (Ferrous sulfate 3–6 mg/kg/day) until hemoglobin normalizes, with vitamin C supplementation to aid absorption.
207
Describe the management for a child diagnosed with Growth Hormone Deficiency (GHD).
Growth hormone therapy using recombinant human GH (rGH).
208
List the four growth phases, their dependencies, and complications.
1. Fetal: Maternal size, placental nutrients; Complications: IUGR, prematurity.
2. Infantile: Nutrition, health, thyroid hormones, genetics; Complications: FTT.
3. Childhood: Nutrition, health, GH & T3; Complications: â GH.
4. Pubertal: Sex hormones, GH; Complications: Early puberty, epiphyseal fusion.
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What percentage of adult height is contributed by each phase?
Fetal: 30%, Infantile: 50%, Childhood: 40%, Pubertal: 15%
210
What causes physiologic weight loss in newborns?
Poor suckling, meconium passage, diluted urine. Regained by day 10.
211
Calculate weight for a 5-year-old using the formula: Wt = (Age à 2) + 8.
(5Ã2) + 8 = 18 kg
212
What is the normal OFC at birth, and how much does it increase in the first year?
Birth: 35 ± 2 cm. Increases by 12 cm in the first year (reaches ~47 cm).
213
How is height measured in infants vs. children >2 years?
Infants: Supine length (infantometer). Children >2: Standing height (stadiometer).
214
What MUAC values indicate malnutrition?
Normal: >12.5 cm, Subclinical: 11.5â12.5 cm, Severe: <11.5 cm
215
What condition is indicated by skin fold thickness <6 mm?
Marasmus (severe protein-energy malnutrition).
216
What color codes are used in MUAC for malnutrition?
Amber = moderate, Red = severe (<115 mm).
217
List laboratory markers of chronic malnutrition.
Low plasma albumin, Hypokalemia, Hyponatremia, Leukocytosis (infection).
218
What is the caloric requirement for a 2-year-old weighing 12 kg?
95 kcal/kg/day à 12 kg = 1,140 kcal/day.
219
Why are infants vulnerable to malnutrition?
Poor fat/protein stores, rapid growth (triple weight by 1 year), illness demands.
220
Define z-scores for severe vs. moderate malnutrition.
Severe: z-score <â3 SD. Moderate: z-score â2 to â3 SD.
221
Compare hair changes in marasmus vs. kwashiorkor.
Marasmus: Sparse, red, brittle. Kwashiorkor: Sparse, light-colored, 'flag sign'.
222
What lab finding distinguishes kwashiorkor?
Hypoalbuminemia (<3.5 g/dL).
223
BMI thresholds for pediatric obesity.
Overweight: >91st percentile. Obese: >98th percentile.
224
What endocrine disorder can cause endogenous obesity?
Hypothyroidism, Cushing syndrome, Prader-Willi syndrome.
225
Explain the 5 Ws risk factors for rickets.
Wrapping, Winter, Windows, Weaning delay, Black race.
226
What bone changes are seen on X-ray in active rickets?
Widening, cupping, fraying of metaphyses; osteopenia.
227
Which vitamin deficiency causes Bitot spots?
Vitamin A (xerophthalmia).
228
Clinical triad of scurvy.
Bleeding gums, joint pain, poor wound healing.
229
Absolute contraindications to breastfeeding.
Maternal HIV (developed countries), infant galactosemia/PKU.
230
How does colostrum differ from mature milk?
Colostrum: High IgA, leukocytes; low fat. Mature milk: High fat (hind milk).
231
Why is lactose in breast milk better tolerated?
Contains β-lactose (slow fermentation) vs. α-lactose (cowâs milk).
232
What foods are introduced at 9â10 months?
Liver, fish, vegetables in soup.
233
Risk of late weaning (>6 months)?
Iron deficiency anemia (IDA), rickets.
234
Causes of bulging anterior fontanelle.
Meningitis, hydrocephalus, encephalitis.
235
What is craniotabes?
Soft, compressible skull (ping-pong ball sensation) â early rickets sign.
236
Rickets Risk Factors
5 Ws (Wrapping, Winter, Windows, Weaning delay, Black race).
237
Marasmus vs. Kwashiorkor
Marasmus = Muscle wasting; Kwashiorkor = Kwashi (edema).
238
Vitamin Deficiencies
B1: Beriberi â 'Beriberi needs B1'. C: Scurvy â 'Curvy gums in C deficiency'.
239
What hormone is crucial for growth in the childhood phase?
Growth Hormone (GH) and T3 (Thyroid hormone).
240
What happens if growth hormone is deficient in childhood?
Short stature, delayed puberty, increased fat mass.
241
What percentage of birth weight is lost in the first few days?
5-10%, regained by day 10.
242
How much weight gain is expected per week in the first 3 months?
150-200 g/week.
243
What is the expected height increase in the first year?
25 cm.
244
At what age does birth length double?
4 years.
245
What is the best age group for using MUAC for malnutrition screening?
6 months - 5 years.
246
Which vitamin deficiency leads to night blindness?
Vitamin A deficiency.
247
What macronutrient is the primary energy source for infants?
Fat (50% of total calories).
248
What does a z-score of -2 indicate?
Moderate malnutrition.
249
Which condition has severe muscle wasting?
Marasmus.
250
What metabolic complications are linked to childhood obesity?
Insulin resistance, Type 2 diabetes, dyslipidemia, hypertension.
251
What is the most common cause of nutritional rickets?
Vitamin D deficiency.
252
Which vitamin deficiency causes Wernickeâs encephalopathy?
Vitamin B1 (Thiamine).
253
What is the primary carbohydrate in breast milk?
Lactose.
254
Why is cowâs milk not recommended before 1 year?
Low iron, high renal solute load, risk of allergies.
255
When should complementary feeding start?
At 6 months.
256
When Should RUTF Be Introduced?
RUTF should be introduced only after the child is clinically stable, meaning: medical complications are resolved, oedema has subsided, and appetite has returned. If the child does not consume at least 75% of the prescribed RUTF within 12 hours, continue with F-75 and attempt reintroducing RUTF after 1–2 days.
257
What Are F-75 and F-100?
F-75 is a low-energy therapeutic milk (75 kcal/100 ml) used in the stabilization phase to restore basic physiological function without overloading the metabolism. F-100 is a higher-energy formula (100 kcal/100 ml) used in the rehabilitation phase to promote weight gain and transition to RUTF or regular food.
258
Why Can't Regular ORS Be Used for Dehydrated Malnourished Children?
ReSoMal is preferred over ORS because ORS has high sodium levels, which can cause fluid overload and heart failure in SAM cases. ReSoMal has lower sodium (45 mmol/L vs. 75 mmol/L in ORS), higher potassium and glucose levels, and contains magnesium, zinc, and copper to correct deficiencies.
259
ORS vs. ReSoMal – Composition Differences
ORS: Sodium (75 mmol/L), Potassium (20 mmol/L), Glucose (75 mmol/L), Osmolarity (245 mOsm/L). ReSoMal: Sodium (45 mmol/L), Potassium (40 mmol/L), Glucose (125 mmol/L), Osmolarity (300 mOsm/L), also contains magnesium, zinc, and copper.
260
When Should IV Fluids Be Used in SAM?
IV fluids should only be used in severe cases such as shock or severe dehydration. Safest IV fluids: Ringer’s lactate with 5% dextrose or Half-strength Darrow’s solution with 5% dextrose. Avoid high-sodium IV fluids as they increase the risk of heart failure and oedema.
261
How to Identify Dehydration in a Malnourished Child?
Signs of dehydration in SAM include lethargy or irritability, very slow skin pinch return (>2 seconds), weak fast pulse, cold hands and feet (sign of shock). If mild dehydration → give ReSoMal orally. If severe dehydration with shock → give IV fluids cautiously.
262
What Happens If a Child Refuses RUTF?
If the child eats less than 75% of the required RUTF in the first 12 hours, continue feeding with F-75 and reintroduce RUTF after 1–2 days. Strategies to encourage intake: offer small, frequent feeds, involve caregivers, ensure no infections or pain. If refusal persists, medical evaluation is needed.
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