16 Growth, Development & Nutrition

VVK16-001
Select the answers.

a. Measure development of a 1-year-old
b. Measure intelligence of a 10-year-old
c. Detection of hemiparesis in a 3-month-old
d. Detection of blindness or deafness in 2-month-old

Options:

i. Clinical neurological examination
ii. Electroencephalogram
iii. Gesell schedules
iv. Thematic apperception test (TAT)
v. Wechsler intelligence scale (WISC) test.

Answer

a. iii (Gesell schedules)
b. v (Wechsler intelligence scale (WISC) test)
c. i (Clinical neurological examination)
d. i (Clinical neurological examination)

VVK16-002
Select the answers.

a. Suicidal behavior
b. Gender identity
c. Oedipal years
d. Latency

Options:

i. 0–2 years
ii. 3–6 years
iii. 6–12 years
iv. 12–14 years
v. 14–16 years.

Answer

a. v (14–16 years)
b. i (0–2 years)
c. ii (3–6 years)
d. iii (6–12 years)

VVK16-003
For each description of development accomplishments, select the earliest most appropriate age.

a. Walk if led and is able to talk a few steps unsupported, demonstrates a good pincer grip, drinks from a cup.
b. Copies a circle, hold on one foot, recognizes colors.
c. Smiles responsively, follows a moving object or face with turning of the head.
d. Kicks a ball, builds a tower of six 1-in cubes, combines two different words.
e. Sits without support, pulls to a stand, babbles loudly and happily, grabs a block with the entire hand.
f. Startles at sudden noise.
g. Draws a triangles, uses past and future tense in language.

Options:

i. 2 Months
ii. 4 Months
iii. 6 Months
iv. 9 Months
v. 12 Months
vi. 18 Months
vii. 2 Years
viii. 3–4 Years
ix. 5 Years.

Answer

a. v (12 Months)
b. viii (3–4 Years)
c. i (2 Months)
d. vii (2 Years)
e. iv (9 Months)
f. i (2 Months)
g. ix (5 Years)

VVK16-004
Nutrition reserve in adult and children—survival without food.
How long can a given subject survive without food?

a. Adults
b. 1 year old
c. Term infant
d. Preterm infant 2 kg
e. Preterm infant 1 kg

Choose from options below:

i. 1 year
ii. 6 months
iii. 3 months
iv. 90 days
v. 45 days
vi. 30 days
vii. 12 days
viii. 4 days
ix. 1 day
x. 12 hours
xi. 1 hour.

Answer

a. iii (3 months)
b. v (45 days)
c. vii (12 days)
d. vii (12 days)
e. viii (4 days)

VVK16-005
The following food substances, which contain vitamin A, need to be arranged based on vitamin A content from low to high.

a. Papaya
b. Guava
c. Drumstick leaves
d. Egg
e. Human milk
f. Carrot.

Answer

Item	Food	Vitamin A (μg/100g)
a.	Guava	0
b.	Human milk	38
c.	Papaya	118
d.	Egg	140
e.	Drumstick leaves	300
f.	Carrot	1167

VVK16-006
Write the calorie value of

a. Rice—1 cup
b. Puri—1
c. Upma—1 cup
d. Idli—1
e. Dosa—1
f. Kichidi—1 cup
g. Boiled egg—1
h. Vada—1
i. Pizza—1 slice
j. Oil—1 tbsp
k. Ice cream—½ cup
l. Peanuts—50 nos
m. Banana—1
n. Cashew nuts—10
o. Milk chocolate—25 g.

Answer

Item	Food & Quantity	Calories (kcal)
a.	Rice—1 cup	170
b.	Puri—1	100
c.	Upma—1 cup	270
d.	Idli—1	75
e.	Dosa—1	125
f.	Khichdi—1 cup	200
g.	Boiled egg—1	90
h.	Vada—1	70
i.	Pizza—1 slice	200
j.	Oil—1 tbsp	60
k.	Ice cream—½ cup	200
l.	Peanuts—50 nos	90
m.	Banana—1	90
n.	Cashew nuts—10	95
o.	Milk chocolate—25 g	140

VVK16-007
A 6-year-old girl comes in OPD with complain of difficulty in vision. The child has a history of recurrent episodes of loose stools and pneumonias. Her weight is 8 kg and height is 82 cm. Her eye examination findings are shown below.

Study the photograph and answer the questions:

VVK-P-Osce 16. Growth, Development & Nutrition_page_2_Picture_16.jpeg

a. What is the positive finding seen in the photograph?
b. What is the most likely diagnosis?
c. Enumerate the WHO staging.
d. What is the staging of the disease in this child?
e. How can you treat this problem at early stages?

Answer

a. Bitot's spot.
b. Vitamin A deficiency (Xerophthalmia).
c. WHO Staging:
- Primary signs:
  - X1A: Conjunctival xerosis
  - X1B: Bitot's spots
  - X2: Corneal xerosis
  - X3A: Corneal ulceration / keratomalacia (< 1/3 corneal surface)
  - X3B: Corneal ulceration / keratomalacia (≥ 1/3 corneal surface)
- Secondary signs:
  - XN: Night blindness
  - XF: Xerophthalmia fundus
  - XS: Corneal scars
d. Stage X1B
e. Xerophthalmia is treated by giving 1,500 μg/kg body weight orally for 5 days followed by intramuscular injection of 7,500 μg of vitamin A in oil until recovery (or age-specific megadoses: 200,000 IU orally on Days 0, 1, and 14).

VVK16-008
Answer the following questions.

a. What are WHO-MGRS charts?
b. List 2 exclusion criteria used in these charts.
c. List 2 advantages of these charts over the CDC/NCHS charts.

Answer

a. WHO—Multicentric growth reference study charts, developed in 2006.
b. Exclusion criteria:
• Formula fed infants
• Children of mothers who smoked during or after the pregnancy
• Morbidities that affect growth (repeated bouts of diarrhea).
c. Advantages:
• The growth charts show how children should grow in all countries.
• MGRS are a standard rather than a reference.
• Any deviation from suggested pattern is evidence of abnormal growth.
• MGRS provide a solid foundation for development of a standard because they are based on healthy children living under condition likely to favor achievement of their full genetic potential.

VVK16-009
Waterlow classification of malnutrition.

An 8-year-old boy is noted to have weight of 67% of expected and height of 83% of expected.

a. What is the degree of malnutrition according to Waterlow Classification?
b. Give details of Waterlow classification of malnutrition.

Answer

a. Severe wasting and severe stunting.
b. Waterlow classification.

	Weight for height (wasting)	Height for age (stunting)
Normal	> 90	> 95
Mild	80–90	90–95
Moderate	70–80	85–90
Severe	< 70	< 85

VVK16-010
The IQ of a 7-year-old child is 40.

a. What is his degree of severity of mental retardation?
b. How do you classify MR on basis of degree of severity?

Answer

a. Moderate mental retardation.
b. Classification of Mental Retardation (DSM-IV / ICD-10):
- Mild mental retardation: IQ level 50–55 to ~70
- Moderate mental retardation: IQ level 35–40 to 50–55
- Severe mental retardation: IQ level 20–25 to 35–40
- Profound mental retardation: IQ level below 20–25
- Mental retardation, severity unspecified: When there is a strong presumption of mental retardation but the child is untestable by standard tests.

VVK16-011
Gomez classification of malnutrition.

A 6-year-old boy is noted to have a weight of 61% of expected and height of 90% of expected.

a. What is the degree of malnutrition according to Gomez classification?
b. Give details of Gomez classification of malnutrition.
c. How do you define mild, moderate and severe malnutrition according to Gomez classification?

Answer

a. Grade 2 (Moderate) malnutrition.
b. Gomez Classification:

Degree of Malnutrition	Weight for Age (% of expected)
Normal	> 90%
Grade I (Mild)	75–90%
Grade II (Moderate)	60–75%
Grade III (Severe)	< 60%

c. Definitions:
- Mild malnutrition: 75–90% of expected weight for age
- Moderate malnutrition: 60–75% of expected weight for age
- Severe malnutrition: < 60% of expected weight for age

VVK16-012
At what age does a child copy the following figures?

a. Square
b. Circle
c. Diamond
d. Vertical stroke

Answer

a. Square: 4 years
b. Circle: 3 years
c. Diamond: 5 years
d. Vertical stroke: 2 years (imitates at 18 months)

VVK16-013
A 9-month-old girl is seen in paediatric OPD for routine measles immunization. She is noted to have a large head with head circumference plotting above 91st centile. During her previous visit her head circumference has been between 75th to 91st centile. Her weight and height is plotted on 50th centile. She is standing with support with no obvious developmental concerns. There are no parental concerns. Her systemic and neurological

examination is entirely normal.

a. Is there reason to be concerned about this child's head growth?
b. What physical findings not present in this case might suggest serious pathology?
c. What is the next step in the evaluation of this baby?
d. What is the most likely diagnosis?
e. What are some additional differential consideration?

Answer

a. Yes. The fact that the head size is showing a progressive increase is more concerning than the size alone.
b. 1. Bulging fontanelle
1. Spread sutures
1. Lethargy
1. Neurologic abnormalities: sun-setting of eye, abnormal tone, delayed development
c. Measure head sizes of parents and siblings
d. Familial macrocephaly
e. Hydrocephalus
Mucopolysaccharide storage disease
Syndromic, i.e. Sotos syndrome (cerebral gigantism).

VVK16-014
A 10-year-old boy is seen in pediatric OPD with parental concerns of being under weight. He has a weight of 39.2 kg and a height of 140cm.

a. What is the formula for calculating BMI?
b. Calculate the BMI of this child.
c. What is your impression about this child's BMI?

Answer

a. $BMI = \frac{Weight in kg}{(Height in meters)^{2}}$
b. $BMI = \frac{39.2}{(1.40)^{2}} = 20 {kg/m}^{2}$
c. Normal BMI (appropriate for age).

VVK16-015
Given below is the BMI centile chart for boys.

Based on the chart below define:

VVK-P-Osce 16. Growth, Development & Nutrition_page_4_Figure_14.jpeg

VVK-P-Osce 16. Growth, Development & Nutrition_page_4_Picture_16.jpeg

a. Underweight
b. Normal weight
c. At risk for overweight
d. Overweight.

Answer

a. Underweight: < 5th percentile.
b. Normal weight: 5th to 84th percentile.
c. At risk for overweight: 85th to 94th percentile.
d. Overweight: > 95th percentile.

VVK16-016
Wellcome classification of malnutrition.

A 5-year-old boy is noted to have a weight of 70% of expected and height of 93% of expected. There is no edema.

a. What is the degree of malnutrition according to Wellcome classification?
b. Give details of Wellcome classification of malnutrition.

Answer

a. Undernutrition
b. Wellcome classification: evaluates the child for edema and with the Gomez classification system.

Weight for age (Gomez)	With edema	Without edema
60–80%	Kwashiorkor	Undernutrition
< 60%	Marasmic-kwashiorkor	Marasmus

VVK16-017
A 14-year-old boy is brought to pediatric OPD with concerns of delayed puberty. On examination, he has preadolescent male genitalia with scanty axillary hairs, and few fine pubic hairs.

a. What is the tanner staging of this child?
i. Stage 1–2
ii. Stage 2–3
iii. Stage 3–4
iv. Stage 4–5
b. What is the first visible sign of puberty in males?
c. At what tanner stage does a male child achieve peak growth velocity?
i. Stage 1–2
ii. Stage 2–3
iii. Stage 3–4
iv. Stage 4–5.

Answer

a. Stage 1–2.
b. Testicular enlargement.
c. Stage 3–4.

VVK16-018
A 11-year-old girl is brought to pediatric OPD with concerns of early signs of puberty. On examination, she has well formed breasts with areola and papilla forming a secondary mound and projecting nipples. She has adult distribution pubic hairs.

a. What is the tanner staging of this child?
b. What is the first visible sign of puberty in females?
c. At what tanner stage does the female attain menarche?
d. Define precocious puberty in girls and boys.

Answer

a. Stage 5.
b. Appearance of breast buds.
c. Stage 3–4.
d. Precocious puberty is defined as the onset of secondary sexual characteristics before 8 years of age in girls and 9 years in boys.

VVK16-019
A 14-month-old male toddler is brought to a pediatrician with parental concerns of delayed eruption of tooth.

a. What is delayed tooth eruption?
b. List 2 common causes.
c. Which is commonly the first tooth to appear?
d. At what age are the following deciduous teeth shed:
- i. First molar
- ii. Maxillary central incisors

Answer

a. Delayed eruption is usually considered when there are no teeth by approximately 13 months of age (mean + 3 standard deviations).
b. Hypothyroidism, Hypoparathyroidism, Familial, Idiopathic (most common).
c. Mandibular central incisors.
d. Shedding age:
- i. First molar: 10–12 years
- ii. Maxillary central incisors: 7–8 years

VVK16-020
Match the following micronutrient with their effects of deficiency.

	Micronutrient		Effects of deficiency
a.	Selenium	i.	Hypercholesterolemia
b.	Manganese	ii.	Impaired glucose tolerance
c.	Fluoride	iii.	Night blindness
d.	Chromium	iv.	Dental caries
e.	Molybdenum	v.	Cardiomyopathy

Answer

Micronutrient	Effects of deficiency
a. Selenium	• Cardiomyopathy (Keshan disease)
b. Manganese	• Hypercholesterolemia
c. Fluoride	• Dental caries
d. Chromium	• Impaired glucose tolerance
e. Molybdenum	• Night blindness / Encephalopathy / Amino acid metabolic defect

VVK16-021
IAP Classification of malnutrition.

A 3-year-old girl is noted have a weight of 55% of expected and height of 91% of expected.

a. What is the degree of malnutrition according to IAP classification?
b. Give details of IAP classification of malnutrition.
c. How do you define severe malnutrition according to IAP classification?

Answer

a. Grade 3 malnutrition.
b. IAP Classification of Malnutrition (based on Weight for Age % of 50th centile):

Grade	Weight for Age (% of expected)
Normal	> 80%
Grade 1 (Mild)	71–80%
Grade 2 (Moderate)	61–70%
Grade 3 (Severe)	51–60%
Grade 4 (Very Severe)	≤ 50%

c. Severe malnutrition according to IAP is Grade 3 and Grade 4 (≤ 60% of expected weight for age).

VVK16-022
Fill in the following table regarding developmental reflexes in normal children:

Reflex	Age of appearance	Age of disappearance
Rooting
Moro
Landau
Parachute

Answer

Reflex	Age of appearance	Age of disappearance
Rooting	Birth	3 months
Moro	Birth	5–6 months
Landau	10 months (or 3-4 months)	24 months
Parachute	8–9 months	Persists for life

VVK16-023
A 14-year-old girl presents in pediatric OPD clinic with complaint of short stature. Her height is 154 cm. Her mother's height is 156 cm and father's height is 167 cm.

a. What is the formula for calculating the mid parental height for girls?
b. What is the mid parental height for this girl?

Answer

a. $Mid-parental height (girls) = \frac{Father’s Height + Mother’s Height - 13}{2}$
b. $Mid-parental height = \frac{167 + 156 - 13}{2} = \frac{310}{2} = 155 cm$

VVK16-024
A 2-month-old infant born at 32 weeks gestation is suspected to have vitamin E deficiency.

a. Name two manifestations which will make you think of vitamin E deficiency in this baby.
b. What is the role of vitamin E in humans?
c. How will you diagnose vitamin E deficiency?
d. Give the content of vitamin E in evion drops.

Answer

a. Thrombocytosis, edema, hemolysis or anemia.
b. Antioxidant.
c. Vitamin E to serum lipids ratio; a ratio <0.8 mg/g is abnormal.
d. 50 mg/mL.

VVK16-025
An 8-month-old boy is reviewed in paediatric OPD for acute gastroenteritis. On detailed history he was noted to have mild developmental delay. No other significant factor was noted in history. On examination, he was noted to have microcephaly. His remaining general and systemic examination was noted to be normal.

a. How do you define microcephaly?
b. List 2 most important investigations for this child.
c. List 4 non-genetic causes of microcephaly.

Answer

a. Microcephaly is defined as a head circumference that measures more than 3 standard deviations below the mean for age and sex (or < -2 SD on standard growth charts).
b. Important investigations: CT/MRI brain, TORCH screening, Metabolic screening, Chromosomal analysis.
c. Non-genetic causes:
- Congenital infections (CMV, rubella, toxoplasmosis, Zika)
- Meningitis / encephalitis
- Hypoxic-ischemic encephalopathy (perinatal asphyxia)
- Metabolic disorders
- Drugs / toxins (Fetal alcohol syndrome)
- Radiation exposure in utero

VVK16-026
A 10-year-old girl presents in pediatric OPD with short stature.

VVK-P-Osce 16. Growth, Development & Nutrition_page_7_Picture_7.jpeg

a. List 3 positive findings seen in the photographs.
b. What is the most likely diagnosis?
c. How would you manage her short stature?

Answer

a. Low hair line/trident hairline. Web neck. Widely spaced nipples.

b. Turner syndrome.
c. GH supplementation.