Pediatric Nutrition and Nutrition related disorders - OSCE Station

Station 1 - Xray

Question

Take a look at the x-ray of a 2year old child who presents with anorexia, vomiting, and poor weight gain.

1. Write the findings on this x-ray.
2. What is your diagnosis?
3. What will be the presenting feature of this condition in an infant?
4. Name the neurological complication that occurs in this condition.
5. Mention one close differential radiological diagnosis.

Answer to Station 1

1. Cortical hyperostosis of ulna and tibia, absence of metaphyseal changes
2. Hypervitaminosis A
3. Bulging fontanel
4. Pseudotumor cerebri
5. Infantile cortical hyperostosis

Station 2 - Metabolic Syndrome

Question

1. What is metabolic syndrome?
2. What is adiposity rebound?
3. Name 2 skin changes that is commonly seen in obese children.
4. Name 4 common comorbidities seen in pediatric obesity.

Answer for station 2

1. Central adiposity, hypertension, dyslipidemia, glucose intolerance, insulin resistance
2. The point at which body fatness declines to a minimum/The point of maximal leanness/minimal BMI. Usually occurs at 5.5years. Early AR – increases the risk of adult obesity
3. Acanthosis nigricans – insulin resistance, Hirsuitism – PCOS
4. Type 2 DM, Hyperlipidemia, hypertension, NAFLD.

Station 3

Question

Answer for station 3

1. Copper b) Osteoporosis
2. Selenium d) Cardiomyopathy
3. Chromium e) Hyperglycemia
4. Manganese a) Hypocholesterolemia
5. Molybdenum c) Central Scotoma

Station 4

Question

1. Identify the condition
2. What is the mode of inheritance?
3. Give the key laboratory findings in this condition.
4. What is the treatment?

Answer for station 4

1. Vitamin D Dependent Rickets – type II
2. Autosomal recessive
3. Calcium – Normal to low, PTH – Normal, 25-OHD – normal, 1,25-diOHD – very high, SAP - high
4. Without alopecia – extremely high doses of vitamin D2, 25- D2, or 1,25 D. (partially functional receptor). If no response to high-dose Vitamin D – long-term IV calcium, later high dose oral calcium.

Station 5

Question

1. What is your diagnosis?
2. Name the common inciting agents for this condition.
3. Name any 2 important predisposing conditions.
4. Name the drugs used in the management of this condition.

Answer for station 5

1. Noma – chronic necrotizing ulceration of gingiva & cheek
2. Fusobacterium necrophorum, prevotella intermedia
3. Measles, malaria, TB, diarrhea, ulcerative gingivitis in a nutritionally compromised host
4. Penicillin, metronidazole

Station 6 - Neonate with prolonged cord stump bleeding

Question

Answer for station 6

1. Vitamin K deficiency bleeding of the newborn
2. Maternal intake of medications – warfarin, phenytoin, phenobarbitone
3. 1mg of parenteral vitamin K

Station 7 - Factors in Breast Milk

Question

Answer for station 7

1. Kills bacteria - Lipase
2. Kills giardia - BSSL
3. Protects against malaria - PABA
4. Inhibits E.coli - Lactoferrin

Station 8

Question - Skeletal Xray

1. Identify the condition.
2. What are the X-ray findings seen in this condition?
3. What are the skin changes seen in this condition?
4. What is the treatment of choice?

Answer for station 8

1. Scorbutic rosary in Vit C deficiency
2. Calcified subperiosteal hematoma, pathological fracture with periosteal reaction, Pencil thin cortex, white line of Frenkel, wimbergers ring sign, Trummerfeld zone, pelkan spur, subperiosteal hemorrhage.
3. Petechial hemorrhages in skin.
4. Vitamin C supplements 100 – 200 mg orally or parenterally, Daily intake of 3 – 4 oz of orange or tomato juice

Station 9 - Successful Breats Feeding

Question

What are the 10 steps for successful breastfeeding?

Answer for station 9

1. Have written breastfeeding policy
2. Training of health care staff
3. Antenatal preparation – education about the benefits of breastfeeding and nipple preparation
4. Early contact – initiation of breastfeeding within 30minutes
5. Guidance – how to feed and how to maintain lactation during separation
6. No food or drinks other than breastfeeds
7. Rooming-in – mother and baby together 24hrs
8. Practice feeding on demand
9. Avoid teats and pacifiers
10. Continuing support through breastfeeding support groups

Station 10 - Nutrition formulas

Question

Answer for station 10

1. DC = Absorbed nitrogen/Food nitrogen X 100
2. BV = Retained nitrogen/Absorbed nitrogen x 100
3. NPU = Retained nitrogen/Food nitrogen X 100
4. PER = gain in weight of experimental animal per unit weight of protein consumed
5. Egg – BV 96, NPU – 96, Cow’s milk – BV 90, NPU – 85

Station 11 - Infant with Chronic diarrhea and skin ulcerations

Question

Answer for station 11

1. Crusting dermatitis in periorificial regions
2. Acrodermatitis enteropathica
3. Zinc deficiency
4. Serum thymulin levels can be used to detect early deficiency
5. 50-150 mg of Zinc sulfate

Station 12 - Infant with dehydration

Question

Answer for station 12

1. 15ml/kg/hr of GRL or 0.45DNS
2. 10ml/kg of whole blood transfusion over 3hrs if Hb <4gm/dl or <6gm/dl with respiratory distress
3. ResoMAL (contraindication – cholera, profuse watery diarrhea). 1 sachet of standard WHO low osmolar ORS in 2litres+1 scoop of commercially available combined mineral & vitamin mix or 40ml of mineral mix solution + 50gm sugar

Station 13 - Recommended Dietary Allowance

Question

Answer for station 13

Vitamin	RDA
Vitamin A	1500 IU
Vitamin E	5-15 IU
Vitamin B3	5-15 mg
Folic Acid	50-150 mcg
Vitamin B12	0.5-1.5 mcg
Vitamin C	40mg
Calcium	500- 1000 mg
Phosphorus	800- 1000 mg
Magnesium	200- 300 mg
Iron	10 – 20 mg
Iodine	50 – 150 mcg
Zinc	5 – 15 mg

Station 14

Question

A mother brings her 4 months old infant to well-baby clinic. How would you counsel her regarding complementary feeds?

Answer for station 14

1. Duration of exclusive breastfeeding and age of introduction of complementary feeds
2. Maintenance of breastfeeding – continue frequent, on-demand breastfeeding until 2years of age
3. Responsive feeding – feed infants directly & assist older children, slowly & patiently, do not force, experiment with different food combinations, avoid distraction, keep talking to the child
4. Safe preparation and storage of complementary feeds – wash hands, clean utensils during preparation, clean cups, bowls for feeding, avoid feeding bottle
5. Amount of complementary feed needed – start with small amounts and increase
6. Food consistency – 6months pureed, mashed, 8months – finger food,
7. 12months – whatever the family eats. Avoid foods that can cause choking
8. Meal frequency and energy density – 2-3 times a day at 6-8months, after that 3-4times a day
9. Nutrient content – rich in micronutrients, avoid drinks with low nutritive value, add nutritional snacks like fruits, bread in between. 30-45% fat content, add oil.
10. Vitamin and mineral supplements or fortified products for infant and mother
11. Feeding during and after illness – increased fluid intake during illness, frequent breastfeeds.

Station 15 - Severe acute malnutrition

Question

As per WHO guidelines, mention the criteria for the diagnosis of severe acute malnutrition (SAM) in children < 6months of age and in children between 6-59 months of age.

1. Name the diet that is recommended during the stabilization phase in SAM. Write the caloric and protein content.
2. Name the diet that is recommended during the rehabilitation phase in SAM. Write the caloric and protein content of the diet.

Answer for station 15

SAM diagnostic criteria for children <6 months

1. Wt for length <3 Z score
2. Bilateral pitting edema

SAM diagnostic criteria for children 6-59 months

1. Wt for height < or = 3 Z score
2. MUAC < 11.5CM
3. Bilateral edema

Diet in SAM

The Diets used in the treatment of SAM are F75 and F 100

F 75 contains 75 kcal, 0.9gm protein/100ml
F 100 contains 100kcal, 2.9gm protein/100ml
Whole/skimmed milk, sugar, veg oil, water, mineral mix (cereal flour)
Ready To Use Therapeutic Food

Few extra points to remember about severe acute malnutrition

Admission criteria

1. Medical complications
2. Severe edema
3. Failed appetite test
4. Danger signs of IMCI
5. The home environment not conducive
6. Recent weight loss or failure to gain weight

Discharge criteria

1. Discharge wt for Ht > 2Z score and no edema for at least 2 weeks
2. MUAC >12.5cm and no edema for at least 2 weeks
3. Good appetite
4. Weight gain >5gm/kg/day for 3 consecutive days

Do not use a percentage of weight gain as a criterion.

Vitamin A recommendation in SAM management

1. If Signs of deficiency – give on day 1, 2 and 15
2. Low dose 5000IU/day daily from admission to discharge
3. High dose if severe diarrhea, shigellosis

Antibiotic recommendation

No apparent danger signs or no complications – oral amoxicillinParenteral antibiotic – septic shock, hypoglycemia, hypothermia, skin, respiratory infections, UTI

HIV and SAM

If the age is < 1year – start ART irrespective of CD4 count or clinical stagingIf the age is between 2 to 5years – start ART for WHO clinical staging 3 or 4, and when CD4 <750 or <25%.

Station 16 - 4 year old with abdominal distention

Question

Answer for station 16

1. Erlenmeyer flask deformity
2. Gaucher disease
3. Autosomal recessive inheritance (More Genetic OSCE)
4. Gaucher cell – wrinkled paper appearance
5. Enzyme replacement therapy

Station 17 - Pedigree chart

Question

1. Identify the pattern of inheritance
2. Write 4 examples

Answer for station 17

1. Mitochondrial inheritance
2. Leber hereditary optic neuropathy, MELAS, MERRF, Leigh disease, Pearson syndrome, Kearn Sayre syndrome, Chronic progressive external ophthalmoplegia

Station 18 - EEG

Question

This is the EEG of a child who is under evaluation for suspected Neurodegenerative disorder.

Answer for station 18

1. Burst suppression episodes, SSPE
2. Stage 2
3. Measles antibody detected in CSF, Characteristic EEG findings (EEG OSCE), Typical histologic findings in/or isolation of virus or viral antigen from brain tissue obtained by biopsy

Station 19 - Case scenario

Question

Answer for station 19

1. True precocious puberty
2. Ultrasound pelvis, GnRH stimulation test, MRI brain
3. Areolar darkening. Growth spurt. Estrogenised vaginal mucosa. Presence of axillary/pubic hair. Progression of pubertal signs. Presence of acne/adult odor. Age of presentation

Station 20 - Case scenario

Question

Answer for station 20

1. Take a critical sample and give IV glucose infusion of 200 mg/kg
2. Insulin, c-peptide, cortisol, growth hormone, lactate, free fatty acids, ketones, alanine
3. Hyperinsulinism, Fatty acid oxidation defect.
4. Diazoxide, chlorothiazide, Octreotide, Subtotal or focal pancreatectomy

Station 21 - Case scenario

Question

Answer for stations 21

1. Celiac disease, cow’s milk protein allergy, giardiasis, immunodeficiency, inflammatory bowel disease
2. Celiac disease
3. Serum IgA tTG, serum IgA Endomysial antibody
4. Positive serology and duodenal biopsy showing villous atrophy while on gluten and clinical improvement on gluten-free diet

Station 22 - Case scenario

Question

Answer for station 22

1. Glutaric Aciduria Type I
2. Low protein diet (restricted in Lysine & Tryptophan ), High dose Riboflavin (200-300mg/day) & L Carnitine(50-100mg/kg)
3. 10 yrs

Station 23 - Write Total Parental Nutrition Order for a 3 yr old boy with weight of 10 kg who is getting all his drugs and infusions in 200ml of 5% dextrose.

Answer for station 22

1. Fluids 100ml/kg = 1000 ml 
2. 200ml 5% dextrose = Calories =10x3.4 = 34 
3. Total calories needed = 1000 
4. Protein 2g/kg = 20gm Fat 3g/kg = 30g x 10 = 300cal 
5. 20% fat 150ml 110 ml 
6.  20% amino acids = 100ml= 80cal 
7. 1000-430 = 590 cal in 600ml 
8. 25% dextrose 600ml = 150 x 3.4 = 510cal

Station 24 - Glycemic index

Question

Arrange the following common Indian food items into any of these 3 categories – low or medium or high glycemic index.

1. Cornflakes
2. Orange
3. Potato (boiled)
4. Brown rice (boiled)
5. Watermelon
6. Whole wheat bread
7. French fries (potato)
8. Banana
9. Chocolate
10. Milk (full fat)
11. Honey
12. Lentils

Answer

Leavng the station open for you to answer

More OSCE Stations

Question

1. OSCE - Interpreting anion gap in OSCE stations
2. OSCE - ABG Drugs and Counselling
3. Examination of a newborn - Pediatric OSCE skills
4. OSCE - Various topics
5. OSCE stations Genetics, ECG and Medical Statistics

Author

Ishita Desai | DNB (Pediatrics) Fellowship in Pediatric Neurology

Ishita completed her Pediatrics residency at Kanchi KamaKoti Childs Trust Hospital, Chennai and received further training in Pediatric Neurology