Malnutrition and Failure to Thrive — MCQs

10 questions

A laborer's younger child is brought to the OPD with a swollen belly and dull face. He has been fed rice water (rice milk) in his diet mostly. On investigations, the child is found to have low serum protein and low albumin. What is the probable diagnosis?

What is the definition of severe acute malnutrition according to WHO criteria?

Which is the most specific clinical feature for diagnosis of Kwashiorkor?

A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

Which is true about an infant with failure to thrive and the following findings?

Most common symptom of HIV infection in infants is:

Which of the following, if normal, would be most significant in making PEM unlikely?

Which of the following is NOT a feature of HIV infection in childhood -

A 2 years baby with 6.7 kg, Hb%- 6 g/dl total protein 3 g/dL, low albumin with distended stomach but no proteinuria. What will be the diagnosis?

Q10

A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

Malnutrition and Failure to Thrive Indian Medical PG Practice Questions and MCQs

Question 1: A laborer's younger child is brought to the OPD with a swollen belly and dull face. He has been fed rice water (rice milk) in his diet mostly. On investigations, the child is found to have low serum protein and low albumin. What is the probable diagnosis?

A. Kwashiorkor (Correct Answer)
B. Kawasaki disease
C. Marasmus
D. Indian childhood cirrhosis
E. Nephrotic syndrome

Explanation: ***Kwashiorkor*** - The symptoms of a **swollen belly** (due to **edema** from low albumin), **dull face**, and a diet primarily of **rice water** (low in protein) are classic signs of Kwashiorkor. - Kwashiorkor is a form of severe protein-energy malnutrition characterized by **protein deficiency** that is greater than the calorie deficit, leading to **hypoalbuminemia** and fluid retention. - The **dietary history** of rice water (carbohydrate-rich but protein-poor) is the key distinguishing feature. *Kawasaki disease* - This is an **acute vasculitis** primarily affecting young children, presenting with fever, rash, conjunctivitis, mouth changes, and lymphadenopathy. - It does not involve a swollen belly or dull face as primary symptoms, nor is it linked to dietary protein deficiency. *Marasmus* - Marasmus is a form of severe malnutrition characterized by an **overall deficiency of calories** and nutrients, resulting in severe **wasting** of muscle and fat. - While it involves low weight and energy deficit, the prominent **edema** (swollen belly) seen in this case points away from marasmus. *Indian childhood cirrhosis* - This is a rare, **fatal liver disease** in young children, often characterized by jaundice, hepatosplenomegaly, and liver failure. - It is not primarily caused by protein deficiency and its symptoms are distinct from the presentation described. *Nephrotic syndrome* - While nephrotic syndrome also presents with **hypoalbuminemia and edema**, it would show **proteinuria** (>3.5 g/day), hyperlipidemia, and lipiduria on urinalysis. - The **dietary history** and absence of urinary findings distinguish kwashiorkor from nephrotic syndrome.

Question 2: What is the definition of severe acute malnutrition according to WHO criteria?

A. Weight for age less than -2 SD
B. Weight for height less than -2 SD
C. Weight for age less than -3 SD
D. Weight for height less than -3 SD (Correct Answer)

Explanation: ***Weight for height less than -3 SD*** - According to the **WHO criteria**, severe acute malnutrition (SAM) is defined by a **weight-for-height Z-score below -3 standard deviations (SD)**. - Other indicators of SAM include a **mid-upper arm circumference (MUAC) less than 115 mm** or the presence of **bilateral pitting edema**. *Weight for age less than -2 SD* - **Weight-for-age below -2 SD** is an indicator of **underweight**, but does not specifically define severe acute malnutrition. - This measure reflects a combination of acute and chronic malnutrition and is insufficient alone to diagnose SAM. *Weight for height less than -2 SD* - **Weight-for-height below -2 SD** signifies **moderate acute malnutrition (MAM)**, not severe acute malnutrition. - This indicates wasting but is not as critical as the -3 SD threshold for SAM. *Weight for age less than -3 SD* - While a low weight-for-age indicates malnutrition, the **-3 SD threshold for weight-for-age** is more indicative of **severe underweight** (a type of chronic malnutrition) rather than specifically severe acute malnutrition, which is primarily characterized by **wasting (low weight-for-height)**. - This measure does not distinguish acute wasting from chronic growth faltering as precisely as weight-for-height.

Question 3: Which is the most specific clinical feature for diagnosis of Kwashiorkor?

A. Edema
B. Fatty liver
C. Low serum albumin
D. Easy pluckable hair (Correct Answer)

Explanation: ***Easy pluckable hair*** - **Easy pluckable hair** is a highly specific clinical sign of Kwashiorkor, indicating severe **protein deficiency** affecting hair follicle integrity. - This symptom, often accompanied by changes in hair color and texture (e.g., **flag sign**), highlights the chronic lack of essential amino acids. *Edema* - **Edema** is a prominent feature of Kwashiorkor, resulting from low **oncotic pressure** due to **hypoalbuminemia**. - While characteristic, edema can also be seen in other conditions like **cardiac**, **renal**, or **hepatic failure**, making it less specific than hair changes. *Fatty liver* - **Fatty liver** (hepatic steatosis) is commonly observed in Kwashiorkor due to impaired synthesis and export of **VLDL** from the liver. - Although characteristic, fatty liver can also occur in **obesity**, **alcoholism**, and **diabetes**, reducing its specificity as a standalone diagnostic feature. *Low serum albumin* - **Low serum albumin** is a hallmark biochemical finding in Kwashiorkor, reflecting severe **protein malnutrition** and reduced hepatic synthesis. - While critical for diagnosis, hypoalbuminemia can also be caused by severe **liver disease**, **nephrotic syndrome**, or **malabsorption**, limiting its specificity for Kwashiorkor alone.

Question 4: A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

A. Hypophosphatemia (Correct Answer)
B. Hypoglycemia
C. Hyperkalemia
D. Hypermagnesemia

Explanation: ***Hypophosphatemia*** * This patient with severe malnutrition (albumin <1, 60lb weight loss) is at high risk for **refeeding syndrome** when TPN is initiated [1]. * Upon refeeding, **insulin release** causes intracellular shifts of electrolytes, particularly phosphate, leading to severe hypophosphatemia [1]. * *Hypoglycemia* * TPN contains dextrose, which typically causes **hyperglycemia**, not hypoglycemia, especially given its continuous infusion. * Hypoglycemia would be more likely if TPN was abruptly discontinued, causing a rapid drop in glucose levels as basal insulin continues to be secreted. * *Hyperkalemia* * Refeeding syndrome typically causes a rapid **intracellular shift of potassium**, leading to **hypokalemia**, not hyperkalemia [1]. * Hyperkalemia would be a concern in patients with renal insufficiency or those receiving potassium-sparing diuretics. * *Hypermagnesemia* * Similar to potassium and phosphate, refeeding syndrome usually causes an **intracellular shift of magnesium**, leading to **hypomagnesemia** [1]. * Hypermagnesemia is rare and typically seen in patients with severe renal failure or excessive exogenous magnesium intake (e.g., antacids).

Question 5: Which is true about an infant with failure to thrive and the following findings?

A. Hypokalemia
B. Metabolic alkalosis
C. Increased urinary sodium (Correct Answer)
D. Increased cortisol

Explanation: ***Increased urinary sodium*** - This image displays an infant with **ambiguous genitalia**, specifically severe clitoromegaly. This is a classic presentation of **congenital adrenal hyperplasia (CAH)** due to **21-hydroxylase deficiency**. - In salt-wasting CAH, deficient **aldosterone** production leads to **renal sodium loss**, resulting in increased urinary sodium, **hyponatremia**, and **hypotension**, contributing to failure to thrive. *Hypokalemia* - **Hypokalemia** is not typically seen in salt-wasting CAH; rather, **hyperkalemia** is more common due to the lack of aldosterone's mineralocorticoid effect, which normally promotes potassium excretion. - The absence of aldosterone causes sodium to be excreted and potassium to be retained. *Metabolic alkalosis* - **Metabolic alkalosis** is not characteristic of salt-wasting CAH; instead, these infants often develop **metabolic acidosis** due to the loss of sodium bicarbonate and impaired acid excretion. - The primary electrolyte disturbance points towards acidosis, not alkalosis. *Increased cortisol* - In 21-hydroxylase deficiency, the enzyme responsible for converting precursors to **cortisol** and aldosterone is deficient, leading to **decreased cortisol** production. - The adrenal glands instead shunt precursors towards androgen synthesis, causing **adrenal hyperplasia** and the virilization seen in the image.

Question 6: Most common symptom of HIV infection in infants is:

A. GI infection
B. Lymphadenopathy
C. Failure to thrive (Correct Answer)
D. Persistent cough

Explanation: ***Failure to thrive*** - **Failure to thrive** is a very common and early symptom of HIV infection in infants, characterized by inadequate weight gain and growth velocity. - Infants with HIV have compromised immune systems, making them susceptible to recurrent infections and chronic inflammation that can lead to growth faltering. *GI infection* - While **gastrointestinal infections** (e.g., chronic diarrhea) are common in infants with AIDS, they are often a *contributing factor* to failure to thrive rather than the single most common *presenting symptom* of AIDS itself. - They can lead to malabsorption and nutrient loss, exacerbating the poor growth associated with HIV. *Lymphadenopathy* - **Generalized lymphadenopathy** is a common sign of HIV infection in infants and children but is often **asymptomatic** and not typically the *MC symptom* that prompts medical attention. - It reflects generalized immune activation but may not be recognized as the primary problem by caregivers. *Persistent cough* - A **persistent cough** can be a symptom of various opportunistic infections in infants with AIDS, such as *Pneumocystis jirovecii* pneumonia (PCP) or recurrent respiratory infections. - While significant, it is a symptom of a specific complication rather than the overarching, most frequently observed sign of untreated HIV.

Question 7: Which of the following, if normal, would be most significant in making PEM unlikely?

A. Lean body mass (Correct Answer)
B. Serum Potassium
C. Skin fold thickness
D. Extracellular fluid (ECF)

Explanation: ***Lean body mass*** - A normal **lean body mass** indicates adequate muscle and organ tissue, which is the primary component affected by **Protein-Energy Malnutrition (PEM)**. - Maintaining normal lean body mass despite potential weight loss makes significant PEM, especially the **marasmic type**, less likely. *Extracellular fluid (ECF)* - **Extracellular fluid (ECF)** can be normal or even increased in cases of **edematous PEM** (kwashiorkor) due to decreased oncotic pressure, making it an unreliable indicator for excluding PEM. - Normal ECF does not rule out the depletion of protein, fat, and muscle mass that characterizes PEM. *Serum Potassium* - **Serum potassium** levels can be normal or abnormal (low or high) in PEM depending on hydration status, renal function, and refeeding syndrome, making it a non-specific indicator for excluding the condition. - It does not directly reflect the overall **nutritional status** or body composition changes seen in PEM. *Skin fold thickness* - **Skin fold thickness** measures subcutaneous fat stores, which can be normal or even preserved in some forms of PEM, particularly **kwashiorkor**, even when severe protein deficiency exists. - While reduced skin fold thickness suggests **marasmus**, a normal value does not conclusively rule out **protein deficiency** or other forms of PEM.

Question 8: Which of the following is NOT a feature of HIV infection in childhood -

A. Failure to thrive
B. Hepatomegaly
C. Kaposi sarcoma (Correct Answer)
D. Lymphoid interstitial pneumonitis

Explanation: ***Kaposi sarcoma*** - While Kaposi's sarcoma is a common HIV-associated malignancy in adults, it is **very rare in HIV-infected children**. - Its presence in children with HIV usually suggests a **more aggressive and rapidly progressing disease course**, but it is not a typical or common feature. *Failure to thrive* - **Failure to thrive** is a very common manifestation of HIV infection in children, often due to **poor nutrient absorption**, increased metabolic demands, and chronic infections. - It leads to **poor weight gain and growth faltering**, negatively impacting overall development. *Hepatomegaly* - **Hepatomegaly**, or an enlarged liver, is a frequent finding in HIV-infected children due to various causes such as **opportunistic infections**, drug side effects, and direct HIV involvement of the liver. - It can be a clinical sign indicating **inflammation or dysfunction** of the liver. *Lymphoid interstitial pneumonitis* - **Lymphoid interstitial pneumonitis (LIP)** is a prevalent pulmonary complication specific to HIV infection in children, characterized by **lymphocytic infiltration of the alveolar septa and peribronchial spaces**. - It often leads to **chronic cough**, hypoxemia, and is considered an **AIDS-defining condition** in pediatric HIV.

Question 9: A 2 years baby with 6.7 kg, Hb%- 6 g/dl total protein 3 g/dL, low albumin with distended stomach but no proteinuria. What will be the diagnosis?

A. None of the options
B. Marasmus
C. Kwashiorkor (Correct Answer)
D. Indian childhood cirrhosis

Explanation: ***Kwashiorkor*** - This condition is characterized by **severe protein deficiency**, leading to **edema** (often manifesting as a **distended abdomen**), low albumin, and **anemia**. - The combination of **low total protein and albumin** with a distended stomach and anemia in a 2-year-old is classic for Kwashiorkor. *Marasmus* - Marasmus is a severe form of **malnutrition** characterized by **extreme thinness** and **wasting of muscle and fat**, without significant edema. - While there is severe weight loss, the classic presenting feature of **edema** (distended stomach in this case due to ascites/edema) and **low albumin** is more indicative of Kwashiorkor. *Indian childhood cirrhosis* - This is a progressive **liver disease** typically seen in young children, characterized by **jaundice**, hepatosplenomegaly, and ascites in later stages. - While it can cause ascites (distended stomach), the primary features in this case point more strongly to **severe protein-calorie malnutrition** rather than a specific liver pathology origin. *None of the options* - The clinical presentation aligns very well with the diagnostic criteria for Kwashiorkor, making this option incorrect. - The presence of **edema (distended stomach), hypoalbuminemia, and anemia** are key features that definitively point to Kwashiorkor.

Question 10: A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

A. VSD (Correct Answer)
B. TOF
C. Patent foramen ovale
D. ASD

Explanation: ***VSD*** - **Ventricular septal defect (VSD)** is the most common cause of this presentation in early infancy (symptoms typically appear at **6-10 weeks** of age). - Large VSDs cause significant **left-to-right shunt** leading to pulmonary overcirculation, resulting in **recurrent pneumonia** and **failure to thrive**. - **Cardiomegaly** (due to volume overload of left atrium and ventricle) and **pulmonary plethora** (increased pulmonary vascular markings) on X-ray are classic findings. - The infant may also present with tachypnea, feeding difficulties, and poor weight gain. *TOF* - **Tetralogy of Fallot (TOF)** is a **cyanotic heart defect** with right-to-left shunt, presenting with cyanosis and hypoxic spells, not recurrent pneumonia. - X-ray shows **boot-shaped heart** and **pulmonary oligemia** (decreased pulmonary vascular markings), not pulmonary plethora. - Does not typically cause failure to thrive in the same manner as acyanotic left-to-right shunt lesions. *Patent foramen ovale* - A **patent foramen ovale (PFO)** is a normal variant in infants and typically remains **asymptomatic**. - Does not cause significant hemodynamic shunting in the absence of elevated right atrial pressure. - Does not cause **cardiomegaly**, **pulmonary plethora**, recurrent pneumonia, or failure to thrive. *ASD* - An **atrial septal defect (ASD)** also causes left-to-right shunt with pulmonary plethora, but the shunt develops **gradually** over time. - ASD typically presents **later in childhood or adulthood** with milder symptoms (fatigue, exercise intolerance) due to lower pressure gradient across atria. - **Recurrent pneumonia and failure to thrive at 10 weeks** are uncommon with isolated ASD, as the hemodynamic changes are less pronounced in early infancy compared to VSD. - When symptomatic in infancy, large ASDs present later (around 6 months to 1 year) rather than at 10 weeks.

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