THG05-001
Read the nutrients in list A as well as B and answer the questions.
a. What is the type of nutrient each group belongs to?
b. What are the differences and significance of these two types?
c. Which of these can be stored up by universal supplementation?
d. List the existing supplementation programs.
Answer
| a. | Type I functional nutrients and type II growth nutrients. |
| b. | Type I: No growth retardation, specific deficiency signs present, and can be stored up in the body. Type II: Growth retardation, no specific deficiency signs, cannot be stored up in the body, and hence to be supplied on a daily basis. |
| c. | Type I functional nutrients. |
| d. | Iron and folic acid (IFA), vitamin A, iodine—universal for all beneficiaries; zinc—targeted or those with diarrhea; vitamin K, vitamin D, and vitamin B12—indicated in special situations such as newborn, infants, and vegans. |
THG05-002
Answer the following questions with regards to fiber intake in diet.
a. What is the requirement of fiber in children?
b. What are the types of fiber?
c. Mention any four items that will give 4 g of fiber each.
d. Mention the positive effects of fiber and negative effects, if any.
Answer
| a. | Requirement: Age in year + 5 g/day. |
| b. | Two types—soluble and insoluble. |
| c. | Each 100 g of the following item provide 4 g of fiber: |
| i. | Bengal gram—3.9 g/100 g, green gram—4.1 g/100 g |
| ii. | Dates—3.9 g/100 g, soybean—3.7g/100 g |
| iii. | One medium root-carrot—4 g, 1 medium fruit orange—4 g |
| d. | Positive effects—increases the bulk of food, prevents constipation, holds water and increase gastrointestinal (GI) transit time, promotes colon health, probiotics and prevent colon cancers, binds bile acids, and reduces blood cholesterol and sugar. Negative effects—very high fiber can bind trace elements such as iron and zinc. |
THG05-003
Gut microbes play a great role in health and disease.
a. List four common gut microbial phyla.
b. Classify them into proinflammatory and anti-inflammatory
c. Role in health and diseases.
d. List four important factors that determine gut microbes.
Answer
| a. | Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, and Fusobacteria. |
| b. | Proteobacteria are proinflammatory and others are anti-inflammatory. |
| c. | Mutualistic gut microbiota–host relationship plays a critical role for many extraintestinal diseases such as metabolic and neurological disorders with “gut–brain axis” interactions. And microbial dysbiosis or imbalance is the cause for several diseases such as inflammatory bowel disease, antibiotic induced diarrhea, and allergic and autoimmune diathesis. Proteobacteria are proinflammatory and others are anti-inflammatory. |
| d. | Factors are gestational age, type of delivery, type of feeding, and environment/echosystem/infections/antibiotics/drugs. |
THG05-004
Answer the following questions regarding JUNCS.
a. Expand the term JUNCS.
b. Define junk food
c. What is NOVA classification system of food items?
d. Give example of each group.
Answer
| a. | J—Junk foods, U—Ultra-processed foods, N—Nutritionally inappropriate foods, C—Carbonated/caffeinated/colored foods/beverages, and S—Sugar-sweetened beverages. |
| b. | Junk foods are HFSS—those which are high in fat, high in salt and high in sugar with very low quantity of other nutrients. |
| c. | NOVA classification categorizes food items into four groups based on the level of processing: |
| Group 1: Unprocessed or minimally processed foods | |
| Group 2: Processed culinary ingredients | |
| Group 3: Processed foods | |
| Group 4: Ultra-processed foods | |
| d. | Formulations of ingredients, mostly of exclusive industrial use, are made by a series of industrial processes, many requiring sophisticated equipment and technology. Processes and ingredients used to manufacture ultra-processed foods are designed to create highly profitable products (low-cost ingredients, long shelf life, and emphatic branding), and convenient (ready-to-consume) hyperpalatable products. |
Many ready-to-consume products such as carbonated soft drinks, sweet or savory packaged snacks, chocolate, candies, ice cream, etc.
THG05-005
Role of folic acid in preventing birth defects.
a. What is the mechanism of action of folic acid in preventing birth defects?
b. Which are all the birth defects can be prevented?
c. In which period it should be administered and at what doses?
d. Is there any side effect of excess folate supplementation?
Answer
| a. | Folate acts through epigenetic mechanisms, by switching off the gene for keeping the neural tube open by methylation of the gene, thus resulting in closure and further normal development. |
| b. | Neural tube defects, conotruncal anomalies and facial. |
| c. | Periconceptional FA-400 µg/day starting at least one month before pregnancy and continuing throughout pregnancy and 4 mg/day in those with affected baby or with extra needs such as anticonvulsants and folate-related polymorphisms. |
| d. | Excess folate supplementation can lead to channeling of excess folate to 5-methyltetrahydrofolate, the so called “folate trap”, which can aggravate any existing vitamin B12 deficiency, rampant among strict vegans. |
THG05-006
Adaptation in a child with chronic malnutrition.
a. How does a child with malnutrition adapts itself to the situation?
b. List five important adaptations.
c. What is the term for immunodeficiency associated with malnutrition?
d. Mention how this differs from other similar conditions.
Answer
| a. | Reductive adaptation. These are for conservation of energy: |
| • | Reducing physical activity and growth |
| • | Reducing basal metabolism by slowing protein turnover |
| • | Reducing the functional reserve of organs |
| • | Slowing the sodium and potassium pumps in cell membranes and reducing their number |
| • | Reducing inflammatory and immune responses |
| b. | Nutritionally acquired immune deficiency syndrome (NAIDS). |
| c. | This affects all levels of immunity like innate and acquired. This simulates human immunodeficiency virus–acquired immunodeficiency syndrome (HIV–AIDS) with increased susceptibility to various infections and candidiasis. |
| d. | The major difference is hypogammaglobulinemia and absence of generalized lymphadenopathy in NAIDS in contrast to HIV–AIDS. |
THG05-007
An infant with severe acute malnutrition (SAM) and severe dehydration was resuscitated and stabilized. Initiated on F-75. On day 4, baby deteriorated → respiratory distress, tachypnea, tachycardia, and hypotension.
a. What is the diagnosis?
b. Pathophysiology of the condition?
c. List out any four complications.
d. Outline the management?
Answer
| a. | Refeeding syndrome. |
| b. | Onset is usually 24–48 hours after the start of high energy feeding. An increase in supply of energy is accompanied by an increase in sodium pump activity, causing rapid release of accumulated sodium from cells, causing expansion of extracellular and plasma volumes. At the same time, there is increased uptake by the cells of glucose, potassium, magnesium, and phosphate, lowering its levels in blood. |
| c. | Hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, fluid retention, respiratory failure, cardiac failure, rhabdomyolysis, leukocyte dysfunction, arrhythmia, seizures, coma, and death. |
| d. | Treatment is correction of the metabolic derangements along with thiamine and supportive care. |
THG05-008
A child with SAM with diarrhea was inadvertently given IV fluid like a normal child.
a. Mention any four clinical signs that will suggest fluid overload.
b. Outline the treatment of dehydration in a child with severe acute malnutirition having sign of shock.
Answer
| a. | Clinical signs that will suggest fluid overload: |
| • | An increase in the respiration rate by 5 breaths/minute or more |
| • | Development of a “grunting” respiration |
| • | Development of crepitations in the lungs |
| • | An increase in heart rate by 15 beats/minute or more |
| • | Development of gallop rhythm |
| • | Increase in liver size by 2 cm |
| b. | Correct fluid management in severe dehydration: |
| • | Ringer’s lactate (RL) with 5% dextrose or ½ normal saline (NS) at 15 mL/kg/h for the first hour (do not use 5% dextrose alone) |
| • | Continue monitoring every 5–10 minutes |
| • | Assess after 1 hour |
| • | If no improvement, consider septic shock |
| • | If improvement is seen, reduce fluid to 10 mL/kg/h till accepting orally |
THG05-009
Answer the following questions regarding management of a child with severe acute malnutrition.
a. What is ReSoMal?
b. What is its composition and osmolarity in comparison to the World Health Organization oral rehydration solution (WHO ORS)?
c. How will you make modified ORS to suit the requirement of a child with SAM? Write the composition.
Answer
| a. | ReSoMal is rehydration solution for malnourished. |
b.
| Item | Reduced osmolarity ORS | ReSoMal | Modified ORS |
|---|---|---|---|
| NaCl (g) | 2.6 | 2.6 | 1.3 |
| KCl (g) | 1.5 | 2.5 | 3 |
| Na citrate (g) | 2.9 | 1.45 + K citrate 0.65 | 1.45 |
| Glucose (g) | 13.5 | 35 | 32 |
| Na (mEq/L) | 75 | 45 | 38 |
| K (mEq/L) | 20 | 40 | 40 |
| Cl (mEq/L) | 65 | 70 | 70 |
| Citrate (mEq/L) | 10 | 7 | 5 |
| Glucose (mEq/L) | 75 | 125 | 122 |
| Osmolarity | 245 | 300 | 300 |
| Composition (mEq/L) | ReSoMal | WHO reduced osmolarity ORS |
|---|---|---|
| Glucose | 125 | 75 |
| Sodium | 45 | 75 |
| Potassium | 40 | 20 |
| Chloride | 70 | 65 |
| Citrate | 7 | 10 |
| Magnesium | 3 | - |
| Zinc | 0.3 | - |
| Copper | 0.045 | - |
| Osmolarity | 300 | 245 |
| Children with SAM are deficient in potassium and have high levels of sodium; hence, ReSoMal with more glucose and potassium and less sodium is preferred instead of standard ORS. These children are deficient in minerals such as magnesium, zinc, and copper which are supplemented by ReSoMal. | |
| c. | Preparation of ReSoMal |
| Step 1: Take one sachet of WHO standard ORS and mix in two litres of water | |
| Step 2: Add 50 g of glucose to that | |
| Step 3: Add 60 mEq of potassium in either of the following way |
| a. | Potclor syrup 45 mL or |
| b. | IV KCL solution 30 mL to be mixed with this solution for oral use |
THG05-010
A 3-year-old child presented with chronic diarrhea, severe stunting, severe pallor, and multiple nutrient deficiencies. Symptoms started after introduction of complementary feeds.
a. What is the likely diagnosis?
b. What is the initial approach to symptomatic patients?
c. What are the food stuffs to be included (list any five)?
d. What are the diets to be excluded (list any five)?
Answer
| a. | Celiac disease. |
| b. | To test for anti-transglutaminase 2 (TG2) immunoglobulin A (IgA) antibodies along with total IgA in serum to exclude IgA deficiency, small intestinal biopsy for villous atrophy. |
| c. | Inclusion list: Rice, corn, maize, millet, fruits, dry fruits, vegetables, non-vegetarian foods, pulses and legumes, sorghum, tapioca, buckwheat, amaranth, quinoa, potato or potato starch, soybean, teff, bean, and nut flours. Wheat starch and products containing wheat starch can be used if they contain <20 ppm gluten. |
| d. | Exclusion list: Wheat, rye, barley gluten, malt, candy, soy sauce, drink mixes, rava, maida, biscuits, bread, pastries, noodles, chocolates, ice creams, and ready to eat soups. |
THG05-011
A 2-year-old child is having chronic diarrhea and repeated respiratory symptoms and had meconium ileus in the newborn period.
a. What is the likely diagnosis?
b. How to confirm?
c. What replacement therapy is recommended to tackle diarrhea and in what dose?
d. How to titrate the dose of replacement?
Answer
| a. | Cystic fibrosis. |
| b. | Quantitative sweat chloride test (>60 meq/L) with one or more of the following–identification of 2 CFTR mutation, typical chronic obstructive pulmonary disease, exocrine pancreatic insufficiency, positive family history. |
| c. | Pancreatic enzyme replacement therapy. |
| d. | Infants generally require 450–900 lipase units/g of fat or 2,000–4,000 lipase units/120 mL of formula or when breastfeeding. Older children and adults generally require 500–4,000 lipase units/g of fat or 500–2,500 lipase units/kg/meal, 250–1,250 lipase units/kg/snack. Doses of enzyme exceeding 2,500 lipase units/kg/meal or 4,000 lipase units/g of fat warrant further investigation. |
THG05-012
A 3-year-old child had angioedema and urticaria while taking food from outside.
a. What is the likely diagnosis?
b. What are the three important factors involved in the pathogenesis of food allergy?
c. Mention four common food allergens.
d. Mention two important preventive strategies?
Answer
| a. | Food allergy. |
| b. | Genetic predisposition, early exposure before leaky gut disappears and defects in gut mucosal barrier. |
| c. | Bovine milk, egg, peanut, soy, wheat, tree nuts, Bengal gram, fish, shellfish, and shrimp. |
| d. | Exclusive breastfeeding for 6 months. Avoid introduction of other foods till 6 months of age in view of leaky guts. Try early oral challenge after 6 months of age. Introduce low risk complementary foods one at a time, followed by potentially highly allergenic foods. Do not avoid allergenic foods during pregnancy or nursing. |
THG05-013
Answer the following questions regarding overweight and obesity.
a. Define overweight and obesity.
b. What complication will you look for in a child with obesity?
c. What are the criteria to diagnose this metabolic complication in children aged 10–16 years?
d. How will you modify the diet and lifestyle?
Answer
| a. | Body mass index (BMI) cut-offs [on Indian Academy of Pediatrics (IAP) 2015 BMI charts] in children aged 5–18 years of 23rd adult equivalent—overweight and 27th adult equivalent—obesity. |
| b. | Metabolic syndrome. |
| c. | Presence of abdominal obesity—waist circumference (WC) ≥90th centile for age, gender, and ethnicity with ≥2 of the following: Triglycerides ≥150 mg/dL, HDL-cholesterol ≥40 mg/dL, fasting blood glucose ≥100 mg/dL, and blood pressure ≥95th centile adjusted for age, height, and gender. |
| d. | Low calorie, high nutrient diet. Stick to three meals and two snacks a day. Promote rainbow diet and traffic signal approach. Switch to healthy snacks like sprouts. Follow 5-2-1-0 rule: 5 or more servings of fruits and vegetables, 2 hours or less recreational screen time, 1 hour or more of physical activity, 0 sugary drinks, and more water. |
THG05-014
A 1.5-year-old child is brought with bowlegs.
a. When will you consider bowlegs as pathological?
b. If pathological mention the probable diagnosis and investigations?
c. Mention the cut off values for vitamin D3.
d. How will you manage?
Answer
| a. | Bowlegs are common up to 2 years of age beyond which it gradually progresses to knock knees. A detailed history and complete examination are warranted to look for associated deformities. Standing inter condylar distance with feet placed together, both malleoli touching each other are measured and a distance of up to 6 cm is considered normal beyond which warrants evaluation. Unilateral deformity, progressive deformity, short stature, intercanine distance/intermolar distance (ICD/IMD) >2 standard deviation (SD) for child’s age should alert for possible pathological deformity. |
| b. | Vitamin D deficiency rickets with low calcium/phosphorous and high alkaline phosphatase. |
| c. | Vitamin D status based on 25-OH vitamin D levels. |
| Deficiency—<12 ng/mL, insufficiency—12–20 ng/mL, and sufficiency— >20 ng/mL. | |
| d. | Treatment of vitamin D deficiency in children: |
| Age | Daily dose for 12 weeks | Alternative intermittent dose regimen | Maintenance dose daily |
|---|---|---|---|
| <6 months | 2,000 IU | NA | 400 IU |
| 6-12 months | 2,000 IU | Equivalent of 2,000 IU/day may be given on a weekly/monthly basis | 400 IU |
| >12 months | 3,000 IU | 60,000 IU every 2 weeks for five doses | 600 IU |
Along with calcium carbonate intake of 50–75 mg/kg/day, maximum 500 mg/day.
THG05-015
A 2-year-old child with intractable seizures significantly improved after her food habits were modified.
a. What is this nonpharmacological intervention that would benefit the child?
b. What is the mechanism behind this approach?
c. Name two conditions in which it is used.
d. Name two vitamin responsive seizures.
Answer
| a. | Ketogenic diet. It is a high fat, low carbohydrate, adequate protein diet with a 3:1 or 4:1 fat:non-fat calorie ratio, well-established as treatment option for intractable epilepsy. |
| b. | This diet mimics starvation state, switch energy source from glucose to free fatty acids which are converted to ketone bodies, the primary energy substrate for brain. |
| c. | Glucose transporter protein-1 deficiency, pyruvate dehydrogenase deficiency, myoclonic astatic epilepsy, tuberous sclerosis complex, Rett syndrome, Dravet syndrome, and infantile spasms. |
| d. | Pyridoxine—antiquitin deficiency associated epilepsies, biotin—biotinidase deficiency, folate—cerebral folate deficiency, biotin/thiamine—biotin-thiamine-responsive basal ganglia disease. |