Parenteral and Enteral Nutrition — MCQs

10 questions

A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

Which of the following is NOT included in the Child-Pugh criteria for assessing liver disease severity?

Which of the following is a complication of total parenteral nutrition?

Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?

In a patient of gastric outlet obstruction nutritional support is best delivered by:

According to WHO guidelines, exclusive breast feeding should be continued for minimum how many months?

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?

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

A patient presents in coma for 20 days, what will be the best way to give him nutrition?

Q10

Which of the following are the common complications associated with enteral nutrition in postoperative patients ? 1. Tube malposition, displacement 2. Diarrhoea, constipation 3. Predisposition to systemic sepsis 4. Electrolytic imbalance Select the correct answer using the code given below :

Parenteral and Enteral Nutrition Indian Medical PG Practice Questions and MCQs

Question 1: A 1-year-old child weighing 6 kg is suffering from acute gastroenteritis with signs of sunken eyes and skin pinch returning to normal very rapidly. What will be your management?

A. RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours
B. RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours
C. RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours
D. RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours (Correct Answer)

Explanation: ***RL infusion 180 ml in the first hour followed by 270 ml in the next 5 hours*** - The child shows signs of **some dehydration** (sunken eyes, skin pinch returning very rapidly). According to **WHO Plan B**, some dehydration requires **75 ml/kg over 6 hours** for rehydration. - For a 6 kg child: **75 × 6 = 450 ml total** - **Distribution:** 30 ml/kg in first hour (180 ml) + 45 ml/kg over next 5 hours (270 ml) - This option provides exactly **450 ml (180 + 270)**, perfectly matching WHO guidelines for some dehydration *RL infusion 120 ml in the first hour followed by 360 ml in the next 5 hours* - First hour: 120 ml = only **20 ml/kg**, which is **below the recommended 30 ml/kg** initial bolus for some dehydration - Total volume: **480 ml** exceeds the required **450 ml** for a 6 kg child - Incorrect fluid distribution pattern for WHO Plan B *RL infusion 180 ml in the first hour followed by 480 ml in the next 5 hours* - First hour volume is correct at **30 ml/kg (180 ml)** - However, next 5 hours: **480 ml = 80 ml/kg**, far exceeding the recommended **45 ml/kg** - Total: **660 ml** significantly exceeds **450 ml**, risking **fluid overload** in a small child *RL infusion 240 ml in the first hour followed by 360 ml in the next 5 hours* - Initial rate: **240 ml = 40 ml/kg** is appropriate for **severe dehydration (WHO Plan C)**, not some dehydration - This child shows **some dehydration** signs, not severe (no lethargy, unconsciousness, or very slow skin pinch) - Total: **600 ml** exceeds the **450 ml** requirement, indicating overtreatment for this clinical scenario

Question 2: Which of the following is NOT included in the Child-Pugh criteria for assessing liver disease severity?

A. ALT / AST (Correct Answer)
B. S. albumin
C. Serum Bilirubin
D. Ascites

Explanation: ***ALT / AST*** - The Child-Pugh score primarily assesses the synthetic and excretory functions of the liver, not necessarily the degree of **hepatocellular inflammation** reflected by transaminases [3]. - While ALT/AST levels are crucial for diagnosing acute liver injury and monitoring chronic liver diseases, they are **not direct components** of the Child-Pugh class, which focuses on prognosis [1]. *S. albumin* - **Serum albumin** reflects the synthetic function of the liver, as albumin is exclusively produced by hepatocytes [2]. - Low albumin levels indicate significant **hepatic dysfunction**, which is directly incorporated into the Child-Pugh scoring system. *Serum Bilirubin* - **Serum bilirubin** measures the liver's ability to conjugate and excrete bilirubin, a key excretory function [2]. - Elevated bilirubin levels signify impaired liver function and are a critical parameter in the **Child-Pugh classification**. *Ascites* - The presence and severity of **ascites** are clinical signs of decompensated liver disease, reflecting portal hypertension and fluid retention [2]. - Ascites is a **clinical parameter** directly included in the Child-Pugh score, contributing to the assessment of disease severity.

Question 3: Which of the following is a complication of total parenteral nutrition?

A. Hyperglycemia (Correct Answer)
B. Hyperkalemia
C. Hyperglycemia and Hyperkalemia
D. Hyperosmolar dehydration

Explanation: ***Hyperglycemia*** - Total parenteral nutrition (TPN) solutions contain a high concentration of **dextrose** (glucose), which can lead to elevated blood glucose levels, especially in patients with pre-existing metabolic issues or high infusion rates. - The sudden and continuous infusion of carbohydrates can overwhelm the body's **insulin response**, resulting in hyperglycemia [3]. *Hyperkalemia* - **Hypokalemia**, rather than hyperkalemia, is a more common electrolyte disturbance associated with TPN due to intracellular shifts of potassium with glucose metabolism [2]. - While TPN solutions do contain potassium, hyperkalemia is generally rare unless there is significant renal impairment or excessive potassium supplementation. *Hyperglycemia and Hyperkalemia* - While **hyperglycemia** is a common complication, **hyperkalemia** is not; in fact, hypokalemia is a more frequent concern linked to the significant glucose load in TPN. - This option incorrectly pairs a common complication with one that is rare and generally only seen in specific circumstances. *Hyperosmolar dehydration* - This condition, also known as **hyperosmolar hyperglycemic state (HHS)**, is a severe complication that can arise from uncontrolled hyperglycemia, where high glucose levels lead to osmotic diuresis and severe dehydration [1]. - While hyperglycemia is a precursor to hyperosmolar dehydration, the direct complication of TPN administration itself is the hyperglycemia.

Question 4: Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?

A. 2, 3 and 4 only
B. 1, 2 and 3 only
C. 1, 3 and 4 only (Correct Answer)
D. 1, 2, 3 and 4

Explanation: ***1, 3 and 4 only*** - **Parenteral nutrition (PN)** is used when the gastrointestinal tract is non-functional or inaccessible, making **enteral nutrition (EN)** impossible or inadequate. - **Hyperglycemia** is a common complication due to the high glucose content in PN solutions, and **liver function abnormalities** (e.g., cholestasis, steatosis) can develop with prolonged use. *2, 3 and 4 only* - This option incorrectly states that the parenteral route is better than the enteral route. **Enteral nutrition** is generally preferred due to being more physiological, safer, and less expensive [1]. - While hyperglycemia and liver dysfunction are correct complications, the assertion about the superiority of the parenteral route is false. *1, 2 and 3 only* - This option incorrectly claims that **parenteral nutrition** is a better choice than the enteral route (statement 2). **Enteral nutrition** is always the preferred route if the gut works [1]. - It also omits **hyperglycemia**, which is a frequent and significant complication of parenteral nutrition. *1, 2, 3 and 4* - This option incorrectly includes statement 2, which suggests the parenteral route is superior to the enteral route. **Enteral nutrition** is always preferred when feasible [1]. - While statements 1, 3, and 4 are correct, the inclusion of statement 2 makes this option incorrect.

Question 5: In a patient of gastric outlet obstruction nutritional support is best delivered by:

A. Enteral nutrition by Ryles tube
B. Jejunostomy (Correct Answer)
C. Gastrostomy
D. Parenteral nutrition

Explanation: ***Jejunostomy*** - In **gastric outlet obstruction**, the stomach cannot empty properly, making gastric feeding routes (like Ryles tube or gastrostomy) ineffective. - A **jejunostomy** allows direct delivery of **enteral nutrition** into the jejunum, bypassing the obstructed stomach and duodenum. *Enteral nutrition by Ryles tube* - A **Ryles tube** delivers nutrition into the stomach, which is obstructed in this condition, leading to **stasis** and **vomiting**. - This method would be ineffective and potentially dangerous due to the inability of gastric contents to pass beyond the obstruction. *Gastrostomy* - A **gastrostomy** involves placing a tube directly into the stomach, which is still part of the obstructed system. - Feeding via gastrostomy would lead to accumulation of feed in the stomach, mimicking the issues with oral feeding or a Ryles tube. *Parenteral nutrition* - **Parenteral nutrition** is a viable option for nutritional support but is generally considered a second-line therapy after **enteral routes** fail or are contraindicated. - **Enteral feeding**, when possible (as with jejunostomy), is preferred due to lower cost, reduced risk of infection, and better maintenance of gut integrity.

Question 6: According to WHO guidelines, exclusive breast feeding should be continued for minimum how many months?

A. 5 months
B. 6 months (Correct Answer)
C. 2 months
D. 12 months

Explanation: ***6 months*** - The **World Health Organization (WHO)** strongly recommends exclusive breastfeeding for the first **six months** of an infant's life. - This provides all the necessary nutrients, antibodies, and fluids for healthy growth and development, without the need for additional food or drinks. *5 months* - While beneficial, stopping exclusive breastfeeding at 5 months is earlier than the **WHO-recommended duration**. - Infants benefit from the continued nutritional and immunological advantages of breast milk up to the six-month mark. *2 months* - Exclusive breastfeeding for only two months is significantly shorter than the **global recommendation**. - This period is insufficient to provide the full spectrum of benefits associated with prolonged exclusive breastfeeding. *12 months* - While breastfeeding can continue for 12 months or longer with complementary foods, **exclusive breastfeeding** is specifically recommended for the first six months. - After six months, complementary foods are introduced alongside continued breastfeeding.

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?

A. Moderate acute malnutrition
B. Acute malnutrition
C. Chronic malnutrition (Correct Answer)
D. Acute or chronic malnutrition

Explanation: ***Chronic malnutrition*** - A **Height-for-Age z-score < -2.5 SD** indicates **stunting**, which is the hallmark of **chronic malnutrition** due to long-term nutritional deprivation. - The **Weight-for-Age z-score < -3.2 SD** (severe underweight) is consistent with chronic malnutrition, as stunted children typically have low weight-for-age. - The **Weight-for-Height z-score of -1.7 SD** is **NOT indicative of wasting** (which requires WHZ < -2 SD per WHO criteria). This value is within the mild range and does not suggest acute malnutrition. - The predominant finding is **chronic malnutrition (stunting)** without evidence of acute malnutrition. *Acute or chronic malnutrition* - While stunting (chronic component) is clearly present, there is **no acute malnutrition** by standard criteria. - Acute malnutrition requires **Weight-for-Height z-score < -2 SD** (moderate) or < -3 SD (severe). - The WHZ of -1.7 SD does not meet the threshold for wasting, so this option incorrectly suggests both components are present. *Moderate acute malnutrition* - **Moderate acute malnutrition (MAM)** is defined by **Weight-for-Height z-score between -2 and -3 SD**. - The given WHZ of -1.7 SD does **not meet** this criterion and therefore does not indicate MAM. *Acute malnutrition* - **Acute malnutrition** is defined by low **Weight-for-Height z-score** (wasting), indicating recent nutritional deficit. - The WHZ of -1.7 SD is **insufficient** to diagnose acute malnutrition (requires < -2 SD). - This option fails to account for the clear evidence of chronic malnutrition (stunting).

Question 8: 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 9: A patient presents in coma for 20 days, what will be the best way to give him nutrition?

A. Ryle's tube feeding (Correct Answer)
B. Feeding via jejunostomy
C. Parenteral nutrition
D. Oral feeding

Explanation: ***Ryle's tube feeding*** - A **Ryle's tube (nasogastric tube)** is the most appropriate method for enteral feeding in a patient who has been in coma for **20 days (~3 weeks)**. - **Current guidelines** recommend NG tube feeding for durations up to **4-6 weeks**, making it suitable for this patient's timeline. - NG tube placement is **non-invasive, quick to establish**, and provides effective enteral nutrition while the patient's neurological status is being assessed and managed. - The gastrointestinal tract is functioning (no contraindication mentioned), making enteral feeding via NG tube the preferred route following the principle: **"If the gut works, use it."** - Proper positioning (head elevation 30-45°) and monitoring can minimize aspiration risk in comatose patients. *Feeding via jejunostomy* - **Jejunostomy** or PEG tube placement is considered for **long-term feeding beyond 4-6 weeks**. - At 20 days, it is **premature** to proceed with a surgical/endoscopic procedure for feeding access unless there are specific indications (recurrent aspiration despite NG feeding, NG tube intolerance, anticipated prolonged need beyond 6 weeks). - Jejunostomy requires a surgical procedure with associated risks and is reserved for patients clearly requiring extended nutritional support. *Parenteral nutrition* - **Parenteral nutrition** (intravenous feeding) is indicated when the gastrointestinal tract is **non-functional** or enteral access is impossible. - Since the question doesn't mention GI dysfunction, enteral feeding is preferred as it maintains gut integrity, is more physiological, safer, and more cost-effective. - Parenteral nutrition carries risks of catheter-related infections, metabolic complications, and gut mucosal atrophy. *Oral feeding* - **Oral feeding** is absolutely contraindicated in a comatose patient due to absent protective airway reflexes and extremely high risk of **aspiration pneumonia**. - A patient in coma cannot safely swallow and protect their airway during oral intake.

Question 10: Which of the following are the common complications associated with enteral nutrition in postoperative patients ? 1. Tube malposition, displacement 2. Diarrhoea, constipation 3. Predisposition to systemic sepsis 4. Electrolytic imbalance Select the correct answer using the code given below :

A. 1, 2 and 4
B. 1, 3 and 4
C. 2, 3 and 4
D. 1, 2 and 3 (Correct Answer)

Explanation: ***1, 2 and 3*** - **Tube malposition/displacement** is a common mechanical complication (10-15% incidence), which can lead to ineffective feeding or aspiration into the respiratory tract. - **Diarrhoea and constipation** are frequent gastrointestinal complications (10-20% incidence), occurring due to formula intolerance, rapid infusion rates, or altered gut motility in postoperative patients. - **Predisposition to systemic sepsis**: While enteral nutrition itself has lower infection risk than parenteral nutrition, complications like **aspiration pneumonia** (from tube malposition), **contaminated formula**, and **prolonged ileus** can predispose to severe infections and sepsis in postoperative patients. This is particularly relevant when enteral feeding is improperly managed. *1, 2 and 4* - This combination includes **electrolyte imbalances** (hypokalemia, hypophosphatemia, hypomagnesemia), which are indeed common metabolic complications requiring monitoring. - However, in the context of postoperative patients, the infection risk (sepsis) from aspiration and feeding-related complications is considered a more significant acute complication than electrolyte disturbances, which are generally manageable with proper monitoring and formula adjustment. *1, 3 and 4* - This option incorrectly excludes **diarrhoea and constipation**, which are among the **most common complications** of enteral nutrition, occurring in 10-20% of patients. - GI complications are a primary reason for enteral feeding intolerance and cannot be omitted. *2, 3 and 4* - This option incorrectly omits **tube malposition/displacement**, which is the most important **mechanical complication** directly related to the enteral feeding method. - Without proper tube placement verification, feeding cannot be safely administered, making this a critical complication to recognize.

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