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PE9.1-7,PE10.1-6,PE11.1-4 | Nutrition Assessment and Support — Graded Quiz
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An 18-month-old girl is brought to a district hospital with a 3-week history of poor feeding, bilateral pedal oedema, and skin flaking over the legs. Examination reveals pitting oedema to the knees, moon face, and 'flaky paint' dermatosis. Her weight-for-height Z-score is −2.0 SD. Her MUAC is 12.8 cm. Which statement BEST describes her nutritional diagnosis and the rationale?
WHO/IAP SAM criteria: any ONE of — WHZ <−3 SD, MUAC <11.5 cm, or bilateral pitting oedema. Bilateral pitting oedema ALONE confirms SAM (kwashiorkor) regardless of the WHZ or MUAC values. The flaky paint dermatosis, moon face, and miserable affect are pathognomonic for kwashiorkor.
The three SAM diagnostic criteria (WHZ <−3 SD, MUAC <11.5 cm, bilateral pitting oedema) are OR criteria — any single one diagnoses SAM. Oedema MASKS wasting (adds apparent weight), so WHZ is unreliable when oedema is present. Always inspect feet for bilateral pitting oedema in every malnourished child.
SAM diagnosis requires any ONE of three criteria: WHZ <−3 SD, MUAC <11.5 cm, or bilateral pitting oedema. When oedema is present, SAM is confirmed even if weight and MUAC appear within a milder range — the oedema masks true wasting. Cardiac oedema is excluded by clinical context (nutritional history, bilateral pedal distribution).
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A 2.5-year-old boy with SAM is in the stabilisation phase (day 5 of F-75 feeding, 3-hourly). The ward nurse is preparing to give the next F-75 feed. Which of the following reflects the CORRECT nutritional principle underlying the use of F-75 rather than F-100 during stabilisation?
F-75 (75 kcal/100 mL, 0.9 g protein/100 mL) is deliberately hypocaloric-hypoproteic to match the severely compromised metabolic capacity of the SAM child — the liver, heart, gut, and kidneys cannot handle high caloric/protein loads in the acute phase. Rapid nutrient loading causes refeeding syndrome (electrolyte shifts, cardiac failure). F-100 (100 kcal/100 mL, 2.9 g protein/100 mL) is for the rehabilitation phase when organ function has recovered.
F-75 stabilisation prevents refeeding syndrome by providing just enough energy to arrest catabolism without overloading the compromised cardiovascular, hepatic, and renal systems. The F-75→F-100 transition is the metabolic 'gear change' after organ recovery, guided by appetite return and oedema resolution.
F-75 has LOWER calorie (75 kcal/100 mL) and MUCH lower protein (0.9 g/100 mL) than F-100 (100 kcal/100 mL, 2.9 g protein/100 mL). The rationale is physiological — a starved child's heart, liver, and kidneys are small and functionally compromised; a sudden high nutrient load causes refeeding syndrome, cardiac failure, and metabolic derangement.
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A paediatrician is counselling the parents of a 3-year-old discharged from the nutrition rehabilitation unit after SAM. The child's weight-for-height has normalised. The parents ask when the child can be considered fully recovered and what follow-up is needed. Which discharge and follow-up criterion is MOST consistent with WHO/IAP recommendations?
WHO discharge criteria from SAM management: WHZ >−2 SD (or MUAC ≥12.5 cm), oedema free for at least 2 weeks, able to eat well, clinically well. Post-discharge follow-up at 1, 2, and 4 weeks, then monthly for 6 months — the highest relapse risk is in the first weeks after discharge.
SAM discharge criteria: WHZ >−2 SD (or MUAC ≥12.5 cm), no oedema ≥2 weeks, eating well, clinically stable. Post-discharge follow-up schedule: weeks 1, 2, 4, then monthly for 6 months. Community health workers (ANM/ASHA) support post-discharge monitoring in India's NRC programme.
Discharge targets WHZ >−2 SD (NOT >−1 SD, which would be an unrealistically high target and delay discharge). Returning to the 50th percentile is not a SAM discharge criterion. Post-discharge follow-up is essential because relapse risk peaks in the early post-discharge period.
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An 8-year-old obese boy is assessed in a paediatric outpatient clinic. The mother reports a family history of type 2 diabetes and hypertension. Physical examination reveals a BMI of 27 kg/m² (BMI-for-age >97th percentile), acanthosis nigricans at the nape, waist circumference 82 cm, and mild hypertension. Which of the following interventions is the MOST evidence-based PRIMARY approach for this child?
IAP/ESPGHAN/AAP guidelines for childhood obesity: lifestyle intervention (physical activity ≥60 min/day moderate-vigorous + balanced hypocaloric diet + behavioural change targeting the family unit) is the first-line treatment. Pharmacotherapy (metformin) is reserved for obese adolescents with insulin resistance failing lifestyle intervention after 6 months, not an 8-year-old as first-line. Bariatric surgery is for adolescents (≥13 years Tanner stage ≥IV) with severe obesity + comorbidities failing all conservative management.
First-line childhood obesity management = intensive lifestyle intervention: structured physical activity ≥60 min/day, reduced-energy balanced diet (NOT severe caloric restriction), behavioural counselling — targeting the WHOLE FAMILY. Screen for comorbidities: insulin resistance (fasting glucose, HbA1c), dyslipidaemia, hypertension, NAFLD, sleep apnoea.
The evidence base for childhood obesity management places lifestyle intervention (physical activity, dietary change, behavioural modification involving the family) as the primary intervention at all stages. Metformin may be used in adolescents with insulin resistance after failed lifestyle change — not as first-line in an 8-year-old. Bariatric surgery has strict age/pubertal stage criteria not met at 8 years.
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A 4-year-old child with SAM is admitted. On examination she has no oedema, WHZ is −3.8 SD, MUAC is 10.8 cm. She is lethargic, has not eaten in 24 hours, and is hypothermic (axillary temperature 35.2°C). As per the WHO 10-step SAM protocol, what should be done FIRST?
WHO 10-step SAM protocol steps 1–3 are hypoglycaemia, hypothermia, and dehydration — addressed FIRST before antibiotics (step 4) or feeding. In a lethargic child, hypoglycaemia and hypothermia are life-threatening emergencies. Check blood glucose; if hypoglycaemic, give 10% dextrose 5 mL/kg IV (or 50 mL of 10% oral glucose if conscious). Simultaneously initiate warming (Kangaroo care, warm environment). F-100 is contraindicated in stabilisation.
WHO 10-step SAM protocol — first three steps are EMERGENCIES: (1) treat hypoglycaemia (10% dextrose 5 mL/kg IV), (2) treat hypothermia (warm environment, Kangaroo care), (3) treat dehydration (ReSoMal 5–10 mL/kg/h). Steps 1–3 may need to be addressed SIMULTANEOUSLY. Antibiotics are step 4 (amoxicillin ± gentamicin).
The WHO 10-step protocol addresses immediate life threats first: step 1 = hypoglycaemia, step 2 = hypothermia, step 3 = dehydration. Antibiotics are step 4. Investigations do not precede emergency stabilisation. F-100 in stabilisation risks refeeding syndrome and cardiac failure.
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A medical student is performing a dietary recall for a 5-year-old child during an outpatient visit. The mother describes the previous day's meals: morning — 1 chapati with dal; afternoon — 1 cup cooked rice with sabzi; evening — 1 cup milk. Using standard Indian food composition tables, which component is the MOST likely to be inadequate compared to RDA?
The ICMR/NIN RDA for calcium in 4–6-year children is approximately 800 mg/day. A single cup of milk (~200 mL) provides ~240–300 mg calcium. Without additional dairy/calcium-fortified foods, total dietary calcium would fall significantly below the RDA. The described diet has adequate energy from grains and adequate protein from dal, making calcium the most likely inadequate micronutrient.
Calcium RDA: 4–6 years = 800 mg/day; 7–9 years = 800 mg; adolescents = 800–1000 mg. One cup milk (~200 mL) ≈ 240–300 mg calcium. Ragi (finger millet) is the highest-calcium Indian food (~360 mg/100 g). Include a 3-day dietary recall for more reliable estimates than a single 24-hour recall.
The described diet (chapati, rice, dal, milk) provides adequate carbohydrate and reasonable protein. Total caloric estimate: 1 chapati ~80 kcal, 1 cup rice ~200 kcal, dal ~100 kcal, 1 cup milk ~150 kcal = ~530–600 kcal, which is below the ~1350 kcal RDA for a 4–6-year-old. However, the question asks for the MOST LIKELY gap in a qualitative recall context where portions may be underestimated. Calcium from a single cup of milk (~300 mg) is conspicuously below the 800 mg RDA.
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A 16-year-old girl with a BMI-for-age of 88th percentile presents complaining of excessive hair loss, cold intolerance, fatigue, and constipation. She has been self-restricting her diet to 'lose weight'. On examination she is pale, with dry skin and brittle hair. Her waist-hip ratio is 0.78. Which nutritional problem is MOST consistent with her presentation?
The clinical picture — cold intolerance, hair loss, fatigue, constipation, dry skin, brittle hair in a self-restricting adolescent girl — is consistent with a hypothyroid-like metabolic state due to severe caloric restriction (thyroid downregulation/euthyroid sick syndrome) and/or iodine deficiency. Dietary restriction also frequently causes iodine deficiency when iodised salt is avoided. BMI at the 88th percentile means overweight but not obese — the presentation is driven by qualitative restriction, not excess.
Adolescent girls engaging in dietary restriction for weight control may develop functional hypothyroidism (euthyroid sick syndrome), iodine deficiency, iron deficiency, and zinc deficiency simultaneously. The hypothyroid-like cluster (cold intolerance, hair loss, constipation, fatigue) in a restricter warrants TSH + T4 + iodine nutritional assessment, not only a haemoglobin check.
The clinical signs (hair loss, cold intolerance, constipation, fatigue, dry skin/hair) are hypothyroid features, not primarily features of anaemia or zinc deficiency alone. The self-restricting diet can cause both functional hypothyroidism (T3/T4 downregulation in starvation) and iodine deficiency if salt is restricted. Zinc deficiency causes hair loss and growth retardation but does not explain the full thyroid-symptom cluster.
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A resident is documenting a diet plan for a 2-year-old recovering from moderate acute malnutrition. The family is vegetarian. The child weighs 10 kg. To meet the estimated caloric requirement of 100 kcal/kg/day during catch-up growth, the plan should provide approximately:
IAP/WHO: for a child in catch-up growth after MAM, the caloric requirement during recovery is approximately 100–150 kcal/kg/day. For a 10 kg child at 100 kcal/kg: 10 × 100 = 1000 kcal/day. This is the maintenance/recovery target; aggressive superfeeding above 150 kcal/kg is not recommended unless in supervised rehabilitation. Holliday-Segar caloric equivalents: 100 kcal/kg for first 10 kg.
Caloric requirement for catch-up growth after MAM: 100–150 kcal/kg/day depending on severity and phase of recovery. Protein requirement during catch-up: 3–4 g/kg/day. Plan diet using balanced Indian foods: cereals + legumes + dairy (or fortified alternatives in vegetarian families) + fat supplementation (oil/ghee) to achieve caloric density.
100 kcal/kg/day for first 10 kg of body weight (Holliday-Segar caloric equivalents) gives 1000 kcal/day for a 10 kg child. 800 kcal (80 kcal/kg) is below the recommended intake. 1500 kcal is too aggressive for unsupervised community catch-up in a 10 kg child (150 kcal/kg = inpatient NRU target).
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A 14-year-old adolescent boy (BMI-for-age 96th percentile) is being counselled regarding obesity prevention strategies. His dietary history reveals: skipping breakfast, daily consumption of sugar-sweetened beverages (3–4/day), and sedentary screen time >5 hours/day. His waist circumference is at the 90th percentile for age. Which of the following is the MOST evidence-based primary prevention strategy to recommend to his family?
IAP/WHO/AAP evidence-based obesity prevention: (1) eliminate or drastically reduce sugar-sweetened beverages (primary modifiable dietary cause); (2) structured physical activity ≥60 min/day moderate-vigorous; (3) limit recreational screen time to <2 hours/day; (4) regular breakfast — skipping is associated with increased BMI and insulin resistance. These four behavioural targets have the strongest evidence base for adolescent obesity prevention and treatment.
Four modifiable adolescent obesity risk behaviours (the 'FAST' framework): Frequency of SSBs, Activity (sedentary), Screen time, and meal Timing (skipping breakfast). Structured lifestyle intervention targeting all four, with family involvement, is the first-line treatment for obese adolescents (BMI-for-age ≥95th percentile).
Orlistat is approved only for adolescents ≥12 years with severe obesity and comorbidities failing lifestyle modification — not first-line. Very-low-calorie diets (<800 kcal/day) are hazardous in adolescents (risk nutritional stunting, bone loss, eating disorders). Endocrinology referral is indicated only when secondary causes (hypothyroidism, Cushing's, PCOS) are clinically suspected — not as a prerequisite for lifestyle modification in simple obesity.
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A community health worker in a tribal block refers a 2.5-year-old child with bilateral oedema and skin changes to the district hospital. On assessment: MUAC 10.2 cm, WHZ −3.6 SD, no fever, fully conscious, eating very little. The team plans to manage the child under the WHO 10-step SAM protocol. In which order should the following three interventions be prioritised in the FIRST hour of admission?
WHO 10-step SAM protocol: the first three steps (hypoglycaemia, hypothermia, dehydration) are emergency steps managed concurrently in the first 30–60 minutes. Blood glucose check (step 1) + warming measures (step 2) + ReSoMal for dehydration (step 3) begin simultaneously; empirical antibiotics (step 4) begin as soon as IV access is established. F-100 is the rehabilitation formula — absolutely contraindicated in stabilisation. IV saline is not recommended in uncomplicated SAM (risk of cardiac overload).
WHO SAM 10-step emergency triage (steps 1–4) are addressed simultaneously, not sequentially: (1) check blood glucose + treat hypoglycaemia (10% dextrose 5 mL/kg IV or 50 mL oral), (2) warm the child (Kangaroo care), (3) ReSoMal for dehydration (NEVER standard IV saline), (4) empirical broad-spectrum antibiotics. F-100 is NEVER used in stabilisation.
F-100 in stabilisation = dangerous (refeeding syndrome risk). IV normal saline is not indicated for dehydration in SAM — use ReSoMal orally/NGT. The concurrent management of steps 1–3 (glucose, warmth, gentle rehydration) with simultaneous antibiotic administration reflects the WHO model. Investigations do not precede emergency stabilisation.
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