Pediatric Nutrition Practice Questions

Q: A young patient presents with enlargement of costochondral junctions, gum bleeding, and a white line of Fraenkel at the metaphysis. The most likely diagnosis is:

Scurvy. ***Scurvy*** - This presentation is classic for **scurvy**, a disease caused by severe **vitamin C deficiency**. - **Enlargement of costochondral junctions** (**rachitic rosary** in scurvy is due to subperiosteal hemorrhage), **gum bleeding** (due to impaired collagen synthesis affecting blood vessel integrity), and the **white line of Fraenkel** (a dense calcified metaphyseal line due to irregular calcification) are characteristic signs of infantile scurvy. *Rickets* - While rickets also causes **rachitic rosary**, it is due to **uncalcified cartilage** and not subperiosteal hemorrhage. - The primary cause is **vitamin D deficiency**, leading to defective bone mineralization, but typically does not cause gum bleeding or the specific "white line of Fraenkel." *Hyperparathyroidism* - Characterized by **increased parathyroid hormone (PTH)**, leading to bone resorption and elevated serum calcium levels. - Presents with symptoms like **bone pain**, **fractures**, and **renal stones**, but not typically gum bleeding or the specific radiological findings seen here. *Osteomalacia* - This is the adult form of **rickets**, caused by **vitamin D deficiency** or impaired phosphate metabolism, leading to inadequate mineralization of new bone (osteoid). - Symptoms include bone pain and muscle weakness, but not the gum bleeding or the specific metaphyseal changes (white line of Fraenkel) seen in childhood scurvy.

Q: A 5-month old formula fed infant has been brought with complaints of watery diarrhoea of 2 days duration and irritability of one day duration. He had been receiving WHO ORS at home. Physical examination reveals a markedly irritable child with a rather doughy skin and rapid pulse. The most likely diagnosis is-

Hypernatremic dehydration. ***Hypernatremic dehydration*** - **Doughy skin**, irritability, and a rapid pulse in an infant with diarrhea are classic signs of **hypernatremic dehydration**. - This condition occurs when water loss exceeds sodium loss, leading to a relatively higher sodium concentration in the body. - Despite receiving WHO ORS, hypernatremic dehydration can still develop if fluid losses are massive or if there is inadequate fluid intake. *Hyponatremic dehydration* - Characterized by **lethargy**, seizures, and a **tense anterior fontanelle** due to brain swelling. - Would typically present with normal or decreased skin turgor, not a "doughy" feel. *Meningitis* - While irritability is present, meningitis would typically also include **fever**, neck stiffness, and possibly a bulging fontanelle, which are not described. - The "doughy skin" is a strong indicator of fluid imbalance rather than central nervous system infection. *Encephalitis* - Presents with significant **neurological symptoms** like altered consciousness, seizures, focal deficits, and fever. - While irritability can be a symptom, it is not accompanied by the characteristic **doughy skin** seen in severe dehydration.

Q: Wimberger sign is seen in ?

Scurvy. ***Scurvy*** - Wimberger sign, characterized by a **dense band of calcified cartilage** at the metaphysis and a **rarefied zone beneath it**, is a classic radiographic sign of scurvy. - It reflects the impaired osteoid synthesis due to **vitamin C deficiency**, leading to weakened bone structure. *Osteoporosis* - Osteoporosis is characterized by **reduced bone mineral density** and increased bone porosity, leading to fragility fractures. - Radiographically, it appears as generalized **osteopenia** with thinning of cortical bone and prominent trabeculae, not specific metaphyseal changes like Wimberger sign. *Osteomalacia* - Osteomalacia is a condition of **defective bone mineralization** after epiphyseal closure, often due to **vitamin D deficiency**. - It presents with **Looser zones (pseudofractures)** and generalized radiolucency, distinct from the metaphyseal changes seen in Wimberger sign. *Rickets* - Rickets is a disorder of **impaired bone mineralization** in children, occurring before epiphyseal fusion, primarily due to **vitamin D deficiency**. - Radiographic features include **widened, cupped, and frayed metaphyses**, distinct from the dense and rarefied bands of Wimberger sign.

Q: Late metabolic acidosis is seen in-

Preterm baby getting cow milk. ***Preterm baby getting cow milk*** - **Preterm infants** have immature kidneys with reduced ability to excrete **acidic metabolites**. - **Cow milk-based formulas** have a higher protein and mineral content, leading to a greater **acid load** which can exacerbate the metabolic acidosis in preterm infants. *Term infant given formula feed* - Term infants generally have more mature renal function capable of handling the **acid load** from formula feeding. - While formula feeding can contribute to a higher renal solute load than breast milk, it rarely results in **late metabolic acidosis** in otherwise healthy term infants. *Long term breast feeding* - **Breast milk** has a lower protein content and a more balanced mineral composition, resulting in a significantly lower **renal solute load** and acid load compared to formula. - It is protective against metabolic acidosis and is the preferred feeding method for infants. *None of the options* - This option is incorrect because **preterm infants fed cow milk-based formula** are indeed at risk for late metabolic acidosis due to their immature kidneys and the higher acid load from the formula.

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

Lean body mass. ***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.

Q: Which nutrient is most deficient in a child with kwashiorkor?

Protein. ***Protein*** - Kwashiorkor is classically defined as **protein deficiency** with relatively adequate calorie intake. - This leads to characteristic symptoms like **edema**, **ascites**, and **muscle wasting**. *Iron* - While **anemia** and iron deficiency can coexist with kwashiorkor, iron is not the primary defining nutritional deficiency. - Iron deficiency typically presents with **pallor**, fatigue, and pica, distinct from the edema seen in kwashiorkor. *Calcium* - **Calcium deficiency** is known to cause conditions like **rickets** (in children) or **osteoporosis** (in adults), affecting bone health. - It does not directly explain the widespread edema and skin changes characteristic of kwashiorkor. *Vitamin D* - **Vitamin D deficiency** primarily affects **bone mineralization**, leading to **rickets** in children and **osteomalacia** in adults. - It is not the main nutrient deficient in kwashiorkor, which is fundamentally a protein deficiency.

Q: Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

Ringer lactate + 5% dextrose. ***Ringer lactate + 5% dextrose*** - This combination provides both **electrolytes** (from Ringer lactate) to help correct **shock** and **glucose** (from 5% dextrose) to address **hypoglycemia** in a child with severe acute malnutrition (SAM). - Patients with SAM are at a high risk of **hypoglycemia** during shock, making glucose supplementation crucial. *Normal saline* - While suitable for initial fluid resuscitation in shock, it does **not contain glucose** and would not address the concomitant hypoglycemia. - Excessive use of normal saline can also lead to **hyperchloremic metabolic acidosis**, which is undesirable in already compromised patients. *Ringer lactate* - Ringer lactate provides **electrolytes** and is a good crystalloid for shock resuscitation, but it **lacks glucose** to correct hypoglycemia. - In SAM patients, where energy stores are depleted, simply providing Ringer lactate might not be sufficient to prevent or treat hypoglycemia. *10% dextrose* - 10% dextrose would effectively treat **hypoglycemia** but is not an appropriate fluid for fluid resuscitation in **shock**. - It would not adequately expand the intravascular volume or provide the necessary electrolytes for managing shock alone.

Q: An 8-month-old child was found to have features of vitamin A deficiency. What is the dose of oral vitamin A required?

1,00,000 IU. ***1,00,000 IU*** - For children aged **6-11 months** with clinical vitamin A deficiency, the recommended dose of oral vitamin A is **1,00,000 IU** (100,000 IU). - An 8-month-old child falls in this age category and requires this specific dose. - This dose is given as part of a **three-dose regimen**: on day 1 (immediately), day 2, and after 2-4 weeks as per **WHO guidelines**. *50,000 IU* - This dose is recommended for **infants less than 6 months** of age with vitamin A deficiency. - Using this dose for an 8-month-old would be **underdosing**, providing inadequate treatment for the deficiency. *75,000 IU* - This is **not a standard dose** for vitamin A supplementation in any age group for deficiency treatment. - Standard WHO guidelines specify 50,000 IU for infants <6 months, 100,000 IU for 6-11 months, and 200,000 IU for children 12-59 months. *2,00,000 IU* - This higher dose is used for children aged **12-59 months** (1-5 years) with vitamin A deficiency. - Administering 200,000 IU to an 8-month-old would be an **overdose**, potentially leading to **acute vitamin A toxicity** with symptoms like bulging fontanelle, vomiting, and irritability.

Question 1

A young patient presents with enlargement of costochondral junctions, gum bleeding, and a white line of Fraenkel at the metaphysis. The most likely diagnosis is:

Accepted Answer

Scurvy

Answer

Rickets

Answer

Hyperparathyroidism

Answer

Osteomalacia

Question 2

A 5-month old formula fed infant has been brought with complaints of watery diarrhoea of 2 days duration and irritability of one day duration. He had been receiving WHO ORS at home. Physical examination reveals a markedly irritable child with a rather doughy skin and rapid pulse. The most likely diagnosis is-

Accepted Answer

Hypernatremic dehydration

Answer

Hyponatremic dehydration

Answer

Meningitis

Answer

Encephalitis

Question 3

Wimberger sign is seen in ?

Accepted Answer

Scurvy

Answer

Osteoporosis

Answer

Osteomalacia

Answer

Rickets

Question 4

Which combination of features is most characteristic of nutritional rickets?

Accepted Answer

Widening of wrists, delayed dentition, muscle hypotonia, bowing of long bones

Answer

Delayed dentition, muscle hypotonia, bowing of long bones

Answer

Widening of wrists, delayed dentition, muscle hypotonia, bowing of long bones, early fontanelle closure

Answer

Growth retardation only

Question 5

Late metabolic acidosis is seen in-

Accepted Answer

Preterm baby getting cow milk

Answer

Term infant given formula feed

Answer

Long term breast feeding

Answer

None of the options

Question 6

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

Accepted Answer

Lean body mass

Answer

Serum Potassium

Answer

Skin fold thickness

Answer

Extracellular fluid (ECF)

Question 7

A 5-year-old has the following anthropometry findings: Weight/age < -3.2 SD, Height/age < -2.5 SD, Weight/height < -1.7 SD. What is the most likely diagnosis?

Accepted Answer

Severe Acute Malnutrition with stunting

Answer

Moderate acute malnutrition

Answer

Chronic malnutrition

Answer

Severe Acute Malnutrition

Question 8

Which nutrient is most deficient in a child with kwashiorkor?

Accepted Answer

Protein

Answer

Iron

Answer

Calcium

Answer

Vitamin D

Question 9

Fluid of choice for shock in a child with severe acute malnutrition + hypoglycemia

Accepted Answer

Ringer lactate + 5% dextrose

Answer

Normal saline

Answer

Ringer lactate

Answer

10% dextrose

Question 10

An 8-month-old child was found to have features of vitamin A deficiency. What is the dose of oral vitamin A required?

Accepted Answer

1,00,000 IU

Answer

50,000 IU

Answer

75,000 IU

Answer

2,00,000 IU

Pediatric Nutrition — MCQs

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