Liver and Nutrition

Question 1

What is the average weight of a term newborn?

Answer 1

3.3kg

Question 2

What is the calorie and protein requirement of a child compared to adults?

Answer 2

Infants-100kcal and 2g protein/kg/day

Adults-35kcal and 1g protein/kg/day

Question 3

What should the average weight gain of a child be?

Answer 3

Double weight by 6 months and triple by 1 year

After 1 year approx 2kg and 5cm/year until puberty

Question 4

What are the benefits of breast milk feeding?

Answer 4

Suckling/bonding 
‘Perfect’ nutrition for 6 months for most infants
Tailor-made passive immunity  (NB HIV)
Development of infant’s active immunity
Development of infant’s gut mucosa
Reduced infection
Antigen load minimal

Question 5

What are the ten steps tp UNICEF ‘Baby Friendly’?

Answer 5

Have a written breast-feeding policy- routinely communicated to all staff.
Train all health care staff in skills necessary to implement this policy.
Inform all pregnant women about the benefits/management of breastfeeding.
Help mothers initiate breastfeeding within a half-hour of birth.
Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
Give newborn infants no food and drink other than breast milk, unless medically indicated.
Practise rooming-in - allow mothers+ infants to remain together - 24h/day
Encourage breast-feeding on demand.
Give no artificial teats, pacifiers (dummies) to breastfeeding infants.
Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

Question 6

What age should babies start being weaned at and with what foods?

Answer 6

5-6 months
Smooth purees cereal,fruit, veg, meat
Lumps/finger foods from 6-7 months
Cup from 7 months

Question 7

What reasons are there to wean a child?

Answer 7

Milk alone inadequate
Source of vitamins and trace elements
Man is an omnivore
Encourage tongue and jaw movements in preparation for speech and social interaction

Question 8

What markers are raised in hepatic disease and which ones in biliary disease?

Answer 8

Hepatic - aspartate aminotransferase and alanine aminotransferase
Biliary-alkaline phosphatase and gamma glutamyl transferase

Question 9

At what level of bilirubin is jaundice usually seen?

Answer 9

40-50 umol/l

Question 10

What are some causes of jaundice in a child less than 24 hours old (early)?

Answer 10

Always pathological
Sepsis
Haemolysis

Question 11

What are some causes of jaundice in a child 24 hours to 2 weeks old (intermediate)?

Answer 11

Physiological
Breast milk
Sepsis
Haemolysis

Question 12

What are some causes of jaundice in a child over 2 weeks old (prolonged)?

Answer 12

Extrahepatic obstruction (biliary)
Neonatal hepatitis
Hypothyroidism (unconjugated)
Breast milk (unconjugated)

Question 13

What is physiological jaundice?

Answer 13

Shorter RBC life span in infants (80-90 days)
Relative polycythaemia
Relative immaturity of liver function
Unconjugated jaundice
Develops after first day of life

Question 14

What type of bilirubin is raised in breast milk jaundice?

Answer 14

Unconjugated jaundice

Can persist up to 12 weeks

Question 15

What is a TORCH screen and when should it be done?

Answer 15

Toxoplasmosis,
Rubella
Cytomegalovirus
Herpes simplex
HIV
Should be carried out in sepsis to find  a cause

Question 16

What are some causes of haemolysis in a newborn and what tests would be done to confirm these?

Answer 16

ABO incompatibility (Blood group, DCT)
Rhesus disease (Blood group, DCT)
Bruising/cephalhaematoma (clinical examination)
Red cell membrane defects (e.g. spherocytosis) (Blood film)
Red cell enzyme defects (e.g. G6PD) (G6PD assay)

Question 17

What is Kernicterus?

Answer 17

Unconjugated bilirubin is fat-soluble (water insoluble) so can cross blood-brain barrier
Neurotoxic and deposits in brain
Early signs – encephalopathy – poor feeding, lethargy, seizures
Late consequences – severe choreoathetoid cerebral palsy, learning difficulties, sensorineural deafness

Question 18

What is the management of unconjugated jaundice?

Answer 18

Phototherapy
Visible light (450nm wavelength) (not UV) converts bilirubin to water soluble isomer (photoisomerisation)

Question 19

What are important tests in a prolonged jaundice?

Answer 19

Split bilirubin (shows levels of conjugated and unconjugated bilirubin)
Look at stool colour

Question 20

What are some causes of biliary obstruction in prolonged jaundice?

Answer 20

Biliary atresia- Conjugated jaundice, pale stools
Choledochal cyst- Conjugated jaundice, pale stools
Alagille syndrome- Intrahepatic cholestasis, dysmorphism, congenital cardiac disease

Question 21

What is biliary atresia?

Answer 21

A fibro-obliterative obstruction of the extrahepatic biliary tree progressing to intrahepatic ducts, which can develop in utero or during the neonatal period.

Question 22

What is the presentation of biliary atresia?

Answer 22

Prolonged conjugated jaundice
Pale stools
Dark urine
Ascites
Hepatomegaly
Can progress to liver failure if not treated

Question 23

What investigations should be done in biliary atresia?

Answer 23

Un/conjugated bilirubin
Abdominal US
PTT
INR
LFTs (raised gamma GT)

Question 24

What is the management of biliary atresia?

Answer 24

Kasai portoenterostomy
Small intestine attached to liver
Chance of success reduces as child gets older so aim to do it before they reach 9 weeks old
If hepatoportoenterostomy is unsuccessful then have to do liver transplantation