Nutrition and Gastroenterology Groups Flashcards
Updated 01/04/2024 (72 cards)
1
Q
How does pasteurization effect the following nutritional components of donated breast milk ?
- Carbohydrates, Protein and Fats
- Inorganic Salt (e.g. Na, K, Cl, Mg, Ca, etc.)
- Fat Soluble Vitamins (K, A, D, E)
- Water Soluble Vitamins
- Beneficial Immune Cells
- Immunoglobulins (IgA, IgM, IgG)
- Lactoferrin and Lysozyme (antibacterial proteins)
- Commensal (or pathogenic) bacteria
- CMV, EBV, HBV, HCV, HIV
A
- Carbohydrates, Fats, Inorganic Salts = Preserved
- Protein = Declines 13 %
- Fat Soluble Vitamins = Preserved
- H2O Soluble Vitamins = Mild drop of B6, B12 Preserved
- Beneficial Immune Cells = 100 % deactivation
- IgA is 67-100%, IgM is 0% and IgG is 70 % active
- Lactoferrin = 80 % active
- Lysozyme = 75 % active
- CMV, EBV, HBV*, HCV*, HIV* = Denatured
- Commensal (or pathogenic) bacteria = KILLED**
*These viruses are screened for prior to pasteurization, if found = sample discarded. **Some spore forming bacterial pathogens can survive pasteurization, if found in any cx the samples are discarded.
2
Q
Give 4 conditions being overweight and/or obese predispose a child, and subsequently young adult to ?
A
- Non-alcoholic Fatty Liver Disease (NAFLD)
- Coronary Artery Disease (CAD) and Stroke risk factors
- Hypertension
- Type 2 Diabetes Mellitus
- Dyslipidemia
- Obstructive sleep apnea
- Osteoarthritis
- Several Cancer (e.g. colorectal, estrogen dependants)
3
Q
What modalities can determine nutritional status in Neurologically Impaired children, where simple growth chart following is difficult ?
A
- Dual Eneregy X-ray Adsorption (DEXA) Scans
- Bioimpedence Analysis (BIA)
- Skin Fold measurements (if above are not feasible)
4
Q
Give 4 Good parental interventions for “picky eaters”
A
Good Interventions (Do’s)
- Minimize non-water fluid intakes (< 750 mL milk, no juice/formulas)
- 15 minutes warnings for meals (mental preparation)
- Restrict water intake shortly before meals (stomach filling)
- Restrict snack ‘grazing’ behaviours
- Expect only 20 Minutes at the Table
- No distractions at the table (no screens, no books, no TV)
- Do not use dinner time for discipline events of the day
- Consistent timing and attendance of all family members
- Praise good completion of meals/trying new things
5
Q
Regarding salt intake, what’s the CPS want you to do, policy wise?
A
- Advocate for legislation on salt content of foods
- Stop marketing high salt foods to children
- Mandatory labelling of high salt foods
- Encourage families to use Nutritional Facts on food
- Educate the public on the salt content in food, and its impact on health
6
Q
TRUE or FALSE
Food labels with ’% of daily’ values assist consumers to restrict their Na intake to below the Chronic Disease Risk Reduction level (CDRR)
A
FALSE
The CDRR for Sodium is < 2000g Na/day. Nutrition labels actually use a ‘% of daily’ required intake for sodium of 2300 g.
7
Q
Which of the following managements for Infantile Colic are evidence based and endorsed by the CPS ?
- Maternal Hypoallergenic Diet (if breastfeeding)
- Hypoallergenic Formula Feeding
- Soy Formula Feeding
- Lactase Supplementation
- Pre-biotics
- Pro-biotics
A
- Maternal Hypoallergenic Diet - Possible Option
- No difference in colic incidence between EBM/BF vs. Formula
- Some benefit from elimination diet; although
- Hypoallergenic Formula Feeding - NOPE
- Never an option outside of severe CMPA/Metabolics
- Do not switch to this instead of EBM (elimination first)
- Soy Formula Feeding - NOPE
- Only for Galactosemia and Cultural reasons (vs. typical formula)
- Lactase Supplementation* - NOPE
- Pre-biotics** - NOPE
- Pro-biotics** - NOPE
*Evidence suggests no benefit. **Insufficient evidence.
8
Q
Describe the sequential management for failure to thrive
A
Failure to Thrive
- Detailed feeding history including psychosocial context*
- Complete physical exam looking for dysmorphic features
- Laboratory Studies including:
- CBC + differential, CRP (or ESR)
- Electrolytes (Na, K, Cl, Mg, PO4, Ca, Mn, Pb + vitamins if concerned)
- Renal and Liver Profiles (BUN, Creat., AST, ALT, ALP, Urinalysis)
- Iron Profile (Total, TIBC, Ferritin)
- Immunoglobulins (IgM, IgA, IgG) and TTG
- TSH
- Consider pursuing additional studies
- uArray and Fragile X (if dysmorphic)
- SweatCl and Fecal Elastase
- Bone Age
- Refer to Feeding Clinic (if persistent without diagnosis)
- Consider Cyproheptadine (appetitogenic) in d/w GI
- Consider G-tube (if feeding is unsafe or nutrition affects underlying illness)
- Never blame parents (people don’t knowingly starve their kids
9
Q
EPI BULLETS
A
- 12 % of children are Obese; 18 % are overweight
- 60 % of children drink sugar sweetened beverages (SSBs)
- Sugar Taxation dropped SSB consumption by 20-50 %*
- SSB is directly proportional to mean BMI scores in children
-
CPS wants :
- 20 % tax on sugar, and to use this tax for health promotion campaigns
- To reassess the impact of SSB access restriction routinely
*11 systematic reviews from different countries/states/provinces found this.
10
Q
What is the iron supplementation plan for babies with birth weights < 2000 g and 2000 - 2500 g?
Why do they need iron ?
A
At 2 weeks of life
- Start 3 mg/kg/day Elemental Iron x 1 year if < 2000 g BW
- OR*
- Start 2 mg/kg/day Elemental Iron x 6 months if 2000-2500g BW
- Re-assess dose Q3months
Iron defeciencies that remain untreated will significantly impact cognitive development
11
Q
What is the definition for Pre-Biotic and Pro-biotic ?
A
Pre-Biotic
Small molecules that modulate the ratios of commensal / pathogenic flora for a overall healthier gut (in the normal patient)
Probiotic
Living organisms of strain shown to be beneficial for the average person’s gut. Their goal is to colonize and shift commensal / pathogenic flora to a favourable ratio, through innoculation.
12
Q
What are the beneficial, and negative, aspects of caffeine?
A
Benefits
- Counteracts sleep deprivation (not cognition loss though)
- Improves muscle endurance
- Improves response time
- Associated with healthy / normal social behaviours (vs. EtOH)
Adverse
- Exacerbates underlying arrythmiae (particularly with overdose)
- Increases T4 production
- Amplifies the stimulation from ADHD medications
- Exacerbates anxiety disorders
- Poor for renal and liver dysfunctional disorders (no explanation)
- Can result in withdrawal if routinely taken
13
Q
When is the physiologic nadir for an infant’s iron?
A
6 Months
14
Q
What are the CPS’ seven principles of nutrition that should be promoted, for a child between 6 - 24 months?
It’s worth noting that these 7 principles have subexplanations that interlock with eachother to create actually 8 principles. This will be reviewed I’m sure.
A
- Exclusive Breastfeeding until 6 Months*
- Vitamin D for Breastfed/Breastmilk kids (400 IU or 800 IU northern)
- Introduce Complimentary foods no later than 9 months**
- Responsive Feeding (i.e. recognising and respecting hunger and satiety)
- Iron Rich foods once solids are introduced
- Safety (Supervise eating, properly store, no undercooked or unpasteurised)
- Quality (No added salt, sugar. No juice or low fat foods, milk <750 mL/day)
- Regular Food Scheduling and Parents Rolemodel etiquette
*The immune group wants to permit the introduction of allergenic foods as early as 4 months for the best outcomes. This contradicts this CPS statement, so you need to evaluate for Allergy Risk before approving/disproving this practice.**New foods should be introduced gradually and should not result in no breastfeeding.
15
Q
What is the mechanism for Fluoride in Dental Carries Prevention ?
A
Topical Fluoride acts in the following ways
- Inhibits plaque production
- Inhibits demineralisation of enamel
- Optimizes Remineralisation of enamel
16
Q
EPI BULLETS
A
- 85 % of Canada resides in urban settings
- 40 % of Pre-schoolers are anemic (usually Fe defeciency)
17
Q
What is the daily iron requirements for the following ages:
- 0 - 6 months
- 6 - 12 months
- 1 - 8 years old
- 9 - 13 years old
- 14+ y.o.
A
Endorsed Daily Iron Requirements by Age
- 0 - 6 m.o. = 1 -2 mg/kg/day
- 6 - 12 m.o. = 11 mg/day
- 1 - 3 y.o. = 7 mg/day
- 4 - 8 y.o. = 10 mg/day
- 9 - 13 y.o. = 8 mg/day
- 14+ y.o. = 15 (fem.) and 11 (male) mg/day
The CPS versus APA steps away from specific numbers for adequate intake. CPS says exclusvie breast feeding is sufficient until 6 months, then push iron rich solids. Do not screen. Do encourage balanced diets (limit milk)
18
Q
EPI BULLETS
A
- Fluorosis rates have increased from 13.5 % to 41.4 % since the introduction of Fluoronated tap water
- 80 - 90 % of Fluorosis cases are mild, with < 20 % severe*
- The Chronic Disease Reduction Rate (CDRR) = 0.7 mm Fluorine
- Systemic (ingested) fluorine does NOT prevent carries
*Severe Fluorosis is identified as requiring cosmetic or reconstructive therapies
19
Q
What is the caloric value, and suggested component of a child’s daily energy intake, for :
Protein
Carbs
Fat
A
-
Protein
- 1 g protein = 4 kcal
- Should only be 10 - 30 % of daily energy intake
-
Carbs
- 1 g carbohydrates = 4 kcal__
- Should be 50 - 65 % of daily energy intake
-
Fat
- 1 g Fat = 9 kcal
- Should be 25 - 30 % of daily energy intake
20
Q
What psychosocial factors does global warming have on children ?
A
- Housing loss or stressors on:
- Prairie wildfires
- Recession of northern land with permafrost thawing
- Flooding along waterways
- Air pollution increasing family disease burden
21
Q
What is the Upper Limit for daily caffeine use ?
A
2.5 mg/kg/day
To give you some perspective here is the content for common drinks:
- Energy drinks (8 oz) = 95 mg
- Instant coffee (8 oz) = 76–106 mg
- Brewed coffee (8 oz) = 118–179 mg
- Black tea (8 oz) = 43 mg
- Green tea (8 oz) = 30 mg
- Regular cola beverage (12 oz) = 36–46 mg
- Chocolate milk (8 oz) = 8 mg
- Hot chocolate (8 oz) = 5 mg
( As a 90 kg man, I should have 225 mg; so ~ 2 cups of coffee )
22
Q
EPI BULLETS
A
- 7 % of annual live births are preterm.
- Human Milk Fortifier has decreased Surgical NEC by 94 % and All NEC by 63 % - for babies < 1250 g.
- Vancouver has the only centralised Human Milk Bank in Canada, while depositories exist throughout the country.
- There is no increased risk for allergic reaction to Donor BM compared to EBM and/or formula.
23
Q
Which of the following conditions have shown evidence of benefit from Probiotic therapy ?
- Neonatal Sepsis
- Anti-biotic Associated Diarrhea
- Clostridium difficile colitis
- Infectious Diarrhea
- Traveller’s Diarrhea
- Cow’s Milk Protein Allergy
- Irritable Bowel Syndrome (IBS)
- NICU enteral feeding tolerance/growth
- Infantile Colic
- Functional GastroIntestinal disorders
- Necrotizing Enterocolitis
- Atopy (asthma, allergic rhinitis, eczema, IgE GI-inflammation, allergies)
- Mild Respiratory / ENT infections
- H. pylori treatment
A
-
Neonatal Sepsis - YES
- LBW and Prem babies with sepsis have reduced mortality
-
Necrotizing Enterocolitis - YES
- Improvement in babies > 1000 g, when coupled w/ breastmilk.
-
Anti-biotic Associated Diarrhea - YES
- Some benefit from L. bacillus
-
Clostridium difficile colitis - Chronic YES, Acute NO
- No benefit in acute treatment. Did drop recurrence by 50 %
- H. pylori - YES with routine therapy
-
Atopy - sort of
- There is recommendation for the prevention of eczema, not other atopic diseases.
-
Infectious Diarrhea - Depends
- Yes for viral aetiology if treated within 48 h of symptoms onset.
- No evidence for bacterial/parasitic diarrheas.
-
Some evidence on prevention, consider if recurrent
* Functional GI Disorders - Depends - Consider only if there is pain associated with the condition
- Traveller’s Diarrhea - Equivocal
-
Irritable Bowel Syndrome (IBS) - Equivocal
- Some noted symptomatic improvements, but call GI for each case
- CMPA - insufficient evidence
- Infantile Colic - Equivocal
- Mild Respiratory / ENT infections - Equivocal
24
Q
Nutrition is generally adequate intake:expenditure
if this is not achieved, how does this impact the growing child ?
A
- Activity related injuries (dislocations, tendon injuries, fractures …)
- Short stature
- Delayed puberty
- Loss of muscle
- Menstrual dysfunction (reflects poor nutrition, doesn’t cause injury)
These are all pathologic things we see in eating disroders - because they are the reflection of an abnormal intake:expenditure ratio which is essential for ED Dx
25
**EPI BULLETS**
* **53 %** of Canadian **schools have** health **food committees** *(2013)*
* **High fat**/**sugar** childhood diet is **1/α to IQ** *(602 patient cohort study)*
* School Nutrition Programs (**SNPs**)\* have been shown to:
* Decrease **BMI**
* **Increase** Access to **Healthy** food
* **Decrease** access to **junk**/bad food
* **+ / -** improve **school performance**\*\*
*\*Precendence for policy changes is the [Arkansas Act](https://encyclopediaofarkansas.net/entries/act-1220-of-2003-7929/) 1220.* *\*\*Studies are mixed results for this measurement, so the CPS won't claim better performance*
26
**EPI BULLETS**
* **3.5 %** of global **intellectual delay** is from **Lead** Poisoning
* **3 %** of **US children** have lead levels **\> 5 ug/dL** *(safe limit)*
* **Half-life** of lead is about **45 days**
* **Risk** for lead poisoning peaks at 2 - 3 y.o.
27
What **micronutrient deficits** are associated with most **anti-epileptic** medications ?
* **Folate** deficits
* **Cobalamine** (B-12) deficits
* Common and Trace elements *(Ca, PO4, Mg, Mn, Zn, Cu)*
* These **must be checked** routinely to screen for nutritional deficits*
* Deficits are associated with hyperhomocystenemia, cardiovascular disease and bone disease.*
28
What **growth parameters** should **always** be documented at each visit/encounter?
* Weight
* Height/Length *(limb measurements for disabled isn't required)*
* BMI
* Ideal Body Weight *(\< 2 y.o.)*
29
What **health** impacts can **global warming** have on children ?
* Increased magnitude and risk for **sun burns**
* **Heat waves** impact children with chronic diseases
* **Renal disease** electrolyte imbalances
* **Heart** **failure** with peripheral dilation
* Asthma/**CF** **exacerbations** with worsening humidity
* **Air Pollution** worsens **resp. disease** incidence & magnitude
* Extension of **Lyme** Disease to farther north
* **Flooding contaminates** bathing **waters** increasing cases of S. *typhi*, Giardia, Cryptosporidium, V*ibrio spp* and Amebiasis
30
**Energy Drink** consumption has been associated with what **negative** health outcomes ?
## Footnote
*(Give 3 examples)*
* Underlying **arrhythmia exacerbations** / unmasking
* **Anxiety** disorder exacerbation
* **Sleep** disorders
* **Increased alcohol** consumption *(when coupled)*
* Delusions
* Agitation
* Cardiovascular collapse\*
* _Death_\*
## Footnote
*\*Secondary to arrythmiae such as sustained SVT, Long QT to Torsades, Trauma from syncope or concomitant alcohol consumption's risky behaviours.*
31
What growth charts can be used for those that are **neurologically impaired**?
* Ideally **Disease Specific** Growth Charts
* **CDC** growth chart can be used **for screening** malnutrition *(although sensitivity is high, specificity is low prompting false positives)*
32
**Define** the nutritional terms "***Chronic Disease Risk Reduction***" (CDRR) and "***Upper Limit***" (UL) regarding exposures
**Chronic Disease Risk Reduction (CDRR)**
The EBM level that, if **exceeded**, **increases** the **risk** of developing a **chronic diseases** associated to the exposure.
Often the target cited in guidelines for food additive exposure
*(e.g. Sodium's CDRR, when exceeded, is associated with hypertension)*
**Upper Limit (UL)**
The highest exposure level to a substance that, **if surpassed**, runs the risk of being acutely/subacutely **toxic**.
*(e.g. Levels of Vitamin A that if ingested, can cause Vitamin A toxicity)*
33
What are the **energy requirements** for a **Neurological Impaired** child, compared to their healthy counterpart for
1. Infants
2. Children
3. Adolescents
* Infants - **Same** *(unless a hemodynamic comorbidity is present\*)*
* Children - **Decreased**
* Adolescents - Significantly **Decreased**
*****The degree of disability is 1/α to the energy requirements*
*\*Examples are congenital heart diseases, cystic fibrosis, chornic anemia, cancers*
34
What are the **calcium** and **vitamin D** requirements for the average child in Canada ?
* Calcium *(oral supplements are typically required to reach target)*
* ***4 - 8** y.o. need **1000** mg per day*
* ***9 - 18** y.o. need **1300** mg per day*
* Vitamin D *(oral supplements are typically required to reach target)*
* ***600** units/day for the **typical** child*
* ***800-2000** units/day for those **up North**\**
## Footnote
*\*Recent studies show that the typical boost of 800 units per day isn't enough to pull most children out of the defecient zone for vitamin D*
35
What is the **differs** between the CDC's and WHO's Growth Charts ?
Which one do all the CPS statements say to use
**Use the WHO Growth Charts**
## Footnote
CDC: Based on american data of both health and unhealthy children
WHO: **International healthy** child data from several **demographics**, **breastfed** to 6 months and **accounts** **for** childhood **obesity**.
36
What is the **microbiome's role** in the **enteral** system, and the **colon**?
_Enteral System_
* Increase **mucin** product
* **Pathogen** competition
* **Immunity** Modulation (via the MALT system)
_Colon_
* Optimize nutrition by **breaking down** extensive **sugars**
* Make vitamins & essentials **bioavailable**
* Promote **water resorption**
* **Acidify** colonic environment *(for absorpn and population control)*
37
**TRUE or FALSE**
## Footnote
Formula feeding results in faster child growth versus breast feeding
**BOTH**
## Footnote
From **0 - 6 months, breastfed** babies grow faster
From **6 - 12 months, formula** fed babies grow faster
38
What is Human Milk screened for upon donation ?
* HIV, HBV, HCV and Human T-Celll leukemia virus
## Footnote
* (The viruses are killed in pasteurization, but screened and discarded just in case)*
* Each sample is **cultured** *before* AND *after* pasteurization
39
**TRUE or FALSE**
## Footnote
A **low salt diet** has been shown to **decrease** you the **blood pressure** and **obesity** rates in healthy children
**FALSE**
## Footnote
Several studies into healthy children, and adults, have shown little to **no change** in BP or BMI from low salt in their diet. However there ARE **benefits** in **normalising salt** content, to below to CDRR.
*So you can still season your food*
40
How do you **manage** mild, moderate and severe **lead poisoning**?
* Mild *(5 - 14 ug/dL)*
* Review results with the family immediately (to cut further family contamination)
* Thorough history for **exposure source**
* Call **Public Health** *(not CAS/DPJ)*
* Start **divalent** cation **replacement** *(Mg, Zn, Ca)*
* Moderate *(14 - 44 ug/dL)*
* Same as above
* **Repeat** level in **1 to 4 weeks**
* Severe *(\> 44 ug/dL)*
* Same as above
* **Abdo. X-ray** for ingested lead containing objects
* Consider **Ligation/Chelation** therapy
* **Repeat** level in **48 h**
* Call **Toxicology**
41
**When** should a family use **fluorinate**d **toothpaste**?
To avoid fluorosis, the family should **only introduce** fluorinated toothpaste **if** their **water** supply **has \< 0.3 ppm Fluorine**
## Footnote
*This information is available on your city/aqueduct website*
42
What are the **acute** and **chronic** effects of **lead tox**icity ?
## Footnote
*(Lead toxicity is \> 5 ug/dL or \> 0.24 uM)*
_**Acute Lead Toxicity *(rare)***_
* Headache, nausea, vomitting
* Hypochromic microcytic **anemia** *(with normal iron levels)*
* **Somnolence**, Clumsiness, **Seizure**
* Death
_**Chronic Lead Toxicity *(insidious)***_
* Developemental and **Intellectual delays**
* **Hypertension**
* **Vascular** Disease
* Chronic **renal** injury
* **Aberrant** behaviours
43
List **3** sources of **Lead** exposure for children
* **Tainted water\*** supply from fracking *(e.g. Flint Michigan)*
* Old **pipes\*** *(for water, not muscles)*
* **Paint\*** in older homes *(Kids with Pica can cause further anemia)*
* Antique **toys** *(figurines AND paint)*
* Ambient **renovation** dust *(old buildings being renovated nearby)*
* **Gasoline\*** fumes *(2nd and 3rd world countries with leaded gas)*
* Maternal **pre-natal** exposures *(Lead crosses the placenta)*
* **Bioaccumulation\*** from imported fruits / vegetables
## Footnote
*Bioaccumulation in the soil, subsequently plants and fertizilers can lead to food we eat being contaminated with lead*
44
**EPI BULLETS**
* **7 %** of Canadian **children** are borderline to **hypertensive**
* **Ex-Prem**ature children's **BPs** are **+37** % more **sensitive** to **salt**
* Canadian numbers for **Sodium** consumption **above** the **CDRR**
* 1 - 3 y.o. : 49 %
* 4 - 8 y.o. : **72 %**
* 9 - 13 y.o. : **79 %** male, **63 %** female
* 14 - 18 y.o. : **92 %** male, 50 % female
45
What are the **physiologic reasonings** behind the development of "**picky eating**" after the age of 2 years old ?
* Slowing **growth rate** *(less relative caloric needs)*
* Desire for **autonomy** *(wants to choose, wants to refuse)*
* **Mimicking** behaviours of siblings/parents *(needs to fit in)\**
## Footnote
*\*This is my favourite CPS statement because for the first time it tells parents to grow up*
46
**EPI BULLETS**
* See the attached photo for GMFCS Definitions
* GMFCS 1 - 5 *(without a feeding tube)* have a **hazard ratio\*** of **2.2** for **complications**, if their weight \< 20th %ile
* GMFCS 2 - 4 have a **hazard ratio** of **1.5** for **death** if \< 20th %ile
*Hazard ratios are the current chance of an event occuring, if a given exposure. Risk Ratio is over a standardized period of time.*
47
What is the CPS' definition of a "Picky Eater" ?
_Picky Eaters_
* **Refusal** of child **to** **expand** their **diet**ary pallet/complete meals
* **Full H&P** should reveal **no** behavioural/psych. **path**ologies
* Must be **recurrent**
* **No acute** psychosocial **stressors**
* When there is a concern raised about eating patterns, it's good to ask the family to supply a 7-day eating log to guide management*
* **25 - 35 %** of all children are defined as "**picky**"*
48
What are the caloric needs for a child of the following ages:
* 4 - 6 y.o.
* 7 - 10 y.o.
* 11 - 14 y.o.
* 15 - 18 y.o.
* 4 - 6 y.o. : **1800** kcal/day
* 7 - 10 y.o. : **2000** kcal/day
* 11 - 14 y.o. : **2500** (Male) **2200** (Fem.) kcal/day
* 15 - 18 y.o. : **3000** (Male) **2500** (Fem.) kcal/day
## Footnote
*Keep in mind that male/female requirements will change when biochemically transitioning gender*
49
What are the **possible negative** side effects of **probiotics**?
The major concern with probiotics, is the risk of **_infection_** through inoculation. There is a concern for Sepsis and Line infection for:
* **Immune compromised** individuals
* Those whom are **critically ill**\*
*\*As an exception, There have been no documented infections of NICU patients with their probiotic microbes in several studies.*
50
**TRUE of FALSE**
## Footnote
Energy Drinks improve both school and sports perfomance
**FALSE**
## Footnote
Over 50 % of adolescents report drinking energy drinks. The top three reasons for adolescents seeking Energy drinks are
1. Improved **School** Performance *(through alertness)*
2. Improved **Sports** Performance *(through energy and alertness)*
3. **Peer** Pressure
**No performance improvement** **has been proven** with evidence. They are, however, *common marketing* tools by *companies*.
51
What's the **equation** for **Daily** **Caloric Needs** in the under/overweight child ?
**Caloric Needs of the Under/Overweight Child**
_(Daily Caloric needs for age *cal/kg/day*) x (Ideal Body Weight *kg*)_
(Current Weight *kg*)
52
How much **water** should a child **drink** for a sports **event**/practice ?
* **600 mL** water 2-3 h **prior** to the event
* 150 - 300 mL water **Q15 min** of event
* ***Electrolytes** added if the event is **\> 1 h**, or it's hot AF*
*Food should be eaten 1 - 2 h prior to the event to prevent cramping and make carbohydrates available for best performance - this with 3 square meals is suggested*
53
Define an overweight and obese child
**Overweight** : Weight z-score of **+1 - 2**
**Obese** : Weight z-score of **\> +2**
*Z-score is the number of sandard deviations from the mean*
54
# Define **C**omprehensive **S**chool **H**ealth framework for holistic health
*(i.e. what the CPS wants all schools to be)*
Comprehensive School Health requires **optimization** of the following aspects of a school
* Social and Physical **Environment** - *e.g. anti-bullying, renovations*
* **Learning** - *e.g. facilitate special needs, modify curriculums*
* **Health** policy - *food access, better food, healty living coursework*
* **Partnership** and Service - *working with paediatricians, city, businesses*
*This model was proven to improve performance and long-term success in several studies around the world*
55
What patients **should** you **screen for lead** poisoning in ?
* **I**mmigrant, **I**ndigenous and S**i**ngle parents *(low socioeconomic)*
* Acquired **intellectual** or **developmental delays**/plateau
* **Abnormal eating** patterns *(i.e. pica, autism or OCD)*
* **Family** history of **lead** intoxication
* Living in **old buildings**
* Ca, Zn or Mg **deficiencies** *(predispose to and develop from Pb poisoning)*
## Footnote
*Remember that Lead is Pb2+, just like Ca2+, Zn2+ and Mg2+ who are important for skin, mucosa and bone integrity. Lead competively interrupts these functions and is stored in the same places as these ions, leading to a long half-life & toxic exposure.*
56
Will "picky eaters" **starve themselves** or fail to thrive because of their pickiness ?
**Nope**
## Footnote
*If your evaluation reveals no pathologies, the child has nutritional tenacity against days of low intake. Respecting satiety is essential for a healthy relationship with food and must be followed. Reassuring the parents and explaining the different physiologic needs of a child can ease stress, which worsens the pickiness.*
57
Give **2 Bad** parental interventions to stop "picky eating"
_Bad Interventions *(Don'ts)*_
* _Force_ feed (directly, through rewards, through punishments)
* Express _frustration_ or anger
* _Give attention_ to picky eating habits
* Expect table manners beyond the child's development
58
What does the **CPS want** you as a Pediatrician **to do** about the **environmental health** concerns of our patients ?
1. **Anticipate** encironmental impacts on chronic disease
2. **Advocate** for pro-environmental policies
3. **Train medical** profs on **environmental** impacts of **disease**
4. **Rolemodel** pro-environment hygiene *(i.e. not what the hospital does)*
59
What is the equation for Mid-Parental Height ?
**_Male_**
(Dad's Height + Mom's Height)/2 + 6.5 cm *+/- 8.5 cm*
**_Female_**
(Dad's Height + Mom's Height)/2 - 6.5 cm *+/- 8.5 cm*
*Mid-parental heights are great for determining if rapid growth in a prem./IUGR kiddo is physiologic or over-feeding/retention*
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What are the differences between Sugar Sweetened Beverages (**SSBs**), **Sports** Drinks and **Energy** Drinks ?
* **S**ugar **S**weetened **B**everages
* Any liquid that has **additional sugar added** to it
* **Includes Juice**, sweet Milks, Energy and Sports drinks
* **Sports** Drinks
* Often sugar sweetened **electrolyte solution**
* Purpose is for electrolyte/sugar **repletion for exercise**
* Only for **sustained** exercise **\> 1h** or **hot/humid weather** conditions
* **Energy** Drinks
* Often sugar sweetened **caffeinated** solutions
* Goal is to achieve **awakened/alert effects** of caffeine
* Can contain **taurine**, gingko/**ginseng**, **Typ**, **Tyr**, Ala and L-carnitine
* **Not recommended** for any consumption
## Footnote
*\*SSB and excessive sports drink consumption is proportional to Obesity and dietary concerns. Energy drinks are associated with several issues, but obesity is yet TBD.*
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Lead-4
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What are the **Rome 3 Criteria** for **Colic**?
## Footnote
*(There are 5)*
_Rome 3 Criteria for Colic_
* **\< 4 months** old
* **Paroxysmal irritability**/crying **without** determined **cause**
* **≥ 3h duration** per episode
* Episodes occur **3/7 days** of the week **for \> 1 week**
* **No** Failure to Thrive (**FTT**)
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Give 4 **risk factors** for a child to have **Iron Deficiency Anemia** in the **first 2 years** of life
_Risk Factors of IDA in the First 2 years of Life_
* **Prem**aturity
* **B**irth**w**eight **\< 2500 g**
* Maternal **Anemia**
* Maternal **Obesity**
* **Early** Umbilical **Cord Clamp**ing
* **\> 6 m.o.** of **ex**clusive **breastfeeding**
* **Lead** exposure
* **Male** sex
* Excessive **Milk** consumption *(low to no solid intake)*
* **Indigenous** Peoples *(10 fold increased incidence of IDA)*
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# Policy
List 2 of the 4 things the **CPS** wants Pediatricians to **advocate** for, regarding **School Nutrition**
The CPS wants you to Advocate for
1. Comprehensive School Health *via* **School Nutrition Programs**
2. **Decreased** access to **junk** food in schools *(and life)*
3. Change school **foods to healthy** options
4. All schools to have a **health food program**
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# Breastfeeding
List 3 restrictions for Mothers to be Breast Milk Donors
_Every **6 Months** the Donor is Checked for the following_
* **Capacity** to follow **sanitary collection** methods
* No **Smoking**
* No Illicity **Drugs**
* No **Alcohol**
* No **OTC** drugs *(although a short list is permitted within a timeframe)*
* **Medically Cleared** by a physician/NP prior to donation
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# Vitamin D
List 6 *(of 8)* **Risk Factors** for **Vitamin D Deficiency**
_Risk Factors for Vitamin D Deficiency_
* **Maternal Vitamin D Deficiency** *(infants)*
* **Darker skin** tone
* Winter and/or **low sun** exposure
* Living **\> 55 northern latitudes** *(the typical criteria for “northern” doses)*
* Low **socio-economic status** and **food insecurity**
* Obesity
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List 5 **signs** of Chronic **Vitamin D Deficiency**
_Signs & Sequelae of Chronic Vitamin D Deficiency_
* Lower limb, Spinal and Skull *(craniotabes)* **defects**
* Enlarged **growth plates** of wrists and ankles on X-ray
* Dilated **costochondral junctions** of ribs palpated and visible on X-ray
* **Hypocalcemia** and subsequent cardiomyopathy
* **Dev**elopmental **Delays** *(Gross Motor, Fine Motor and IQ)*
* **Failure to thrive**
* Abnormal **Dentition**
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Describe **Non-pharmacologic** managements for infantile **GERD**
Non-Pharmacologic Management of GERD
* **Thickened** feeds *(2 week trial)*
* Cow's Milk Protein **elimination** *(2 week trial)*
* Vertical holding a of the child afterfeeds is ok
**do NOT angle the bed** outside of inpatient care/monitoring.
| CMPA can mimic GERD, so the elimination is to remove a confounder.
## Footnote
https://cps.ca/en/documents/position/gastro-esophageal-reflux-in-healthy-infants
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Describe **pharmacologic** managements for infantile **GERD**
Pharmacologic Management of Infantile GERD
* **Acid suppression** shows no clear benefit to clinical outcomes, and is associated with infection risks in all weight categories. It **should be avoided if the child is otherwise well**
* Acid suppresion can be used in children who are failing to thrive or show signs of erosive eosophagitis.
* There is **no sufficient evidence** to support the use of **pro-kinetics** in the management of infantile GERD
| There isn't a good pharmacologic management for these things.
## Footnote
https://cps.ca/en/documents/position/gastro-esophageal-reflux-in-healthy-infants
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What the **risk factors** for reduced **Bone Mass ?**
**Reduced Bone Mass Risk Factors**
1. Chronic inflammation
2. Reduced physical activity/muscle mass
3. Intrinsic Pubertal delay
4. Nutritional deficiencies
5. Medications
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What are the **pediatric** criteria for **diagnosing** **osteoporosis** ?
**Pediatric Osteoporosis**
*One of the three clinical scenarios:*
1. 1+ verterbral fracture in the absence of high-energy trauma or local infiltrative disease *(e.g. tumour, abscess)*
2. **2+ long bone fractures** by the age of 10 years old **WITH** a **≥ -2 Z-score for BMD**
3. **3+ long bone fractures** before the age of 19 years old **WITH** a **≥ -2 Z-score for BMD**
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