Pediatric Nutrition and Nutrition related disorders - OSCE Station


Station 1 - Xray

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

X-ray in Hypervitaminosis A
Fig.1 - Xray of child with Anorexia and Failure to thrive.
  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

  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

Match the following

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

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

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  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

Noma – chronic necrotising ulceration of gingiva and cheek
Fig.4 - Chronic ulceration.
  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

A 6hrs old term neonate has prolonged bleeding from the umbilical stump. PT is 24 seconds and PTT is 50seconds. Platelet count is 3lakhs/cumm. Sepsis screening is negative.

  1. What is the most likely diagnosis?
  2. Mention one important antenatal history that you will elicit.
  3. What is the treatment of choice?

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

Which factors in breast milk do which function? Answer the following.

  1. Kills bacteria ------
  2. Kills giardia -------
  3. Protects against malaria -------
  4. Inhibits E.coli --------

Answer for station 7

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

Station 8

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  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

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

Write down the formula's / Calculations for the following

  1. Digestibility coefficient
  2. Biological value
  3. Net protein utilization
  4. Protein efficiency ratio
  5. Write the BV and NPU of egg and cow’s milk.

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

zinc deficiency in children
Fig 7 - Infant with chronic diarrhea

This infant shown in the image below is under evaluation for chronic diarrhea.

  1. Describe the lesions
  2. What is your diagnosis?
  3. What is it due to?
  4. How will you detect in its early stages?
  5. How do you treat?

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

An 8months old infant with a history of recurrent diarrhea and poor weight gain is brought with complaints of loose stools for a day. On examination, the infant is lethargic, pale, undernourished with a weight of 4kg. Edema is present. The oral mucosa is dry. Pulses are feeble.

  1. What is the recommendation regarding initial fluid management in this infant?
  2. What is the recommendation regarding blood transfusion in this infant?
  3. What is the type of ORS that can be used in this infant and how to prepare it?

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

Write the RDA of the following

  1. Vitamin A
  2. Vitamin E
  3. Vitamin B 3
  4. Folic acid
  5. Vitamin B 12
  6. Vitamin C
  7. Calcium
  8. Phosphorus
  9. Magnesium
  10. Iron
  11. Iodine
  12. Zinc

Answer for station 13

Vitamin A1500 IU
Vitamin E5-15 IU
Vitamin B35-15 mg
Folic Acid50-150 mcg
Vitamin B120.5-1.5 mcg
Vitamin C40mg
Calcium500- 1000 mg
Phosphorus800- 1000 mg
Magnesium200- 300 mg
Iron10 – 20 mg
Iodine50 – 150 mcg
Zinc5 – 15 mg
Table showing recommended RDA

Station 14

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

As per WHO guidelines, mention the criteria for the diagnosis of 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 things extra on SAM

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

Note - 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 amoxicillin
Parenteral 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 staging
If the age is between 2 to 5years – start ART for WHO clinical staging 3 or 4, and when CD4 <750 or <25%.


Station 16

Fig.8 - Xray femur

This is the x-ray of a 4year old child who presents with easy fatiguability, easy bruising, limb pain and progressively increasing abdominal distension.

On examination, he has pallor, few petechiae and massive splenomegaly, moderate hepatomegaly.

  1. What is the finding of this x-ray?
  2. What is the most likely diagnosis?
  3. What is the mode of inheritance?
  4. What will be the bone marrow finding in this child?
  5. What is the treatment of choice?

Answer for stationS 16

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

Station 17

Fig.9
  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

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

Fig.10 - EEG
  1. What is the most likely diagnosis?
  2. At what stage of illness does this EEG pattern occur?
  3. Other than the compatible clinical course, what are the 3 supportive findings that are used in the diagnosis of this condition?

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

5 years old girl has presented with breast enlargement for the past 1 year. Her height has increased from 95 to 106 cm in the last 1 year. The SMR staging is breast stage 2, axillary hair- stage 1, and pubic hair stage 1.

X-ray bone age is consistent with the age standard of 8 years. Investigations show FSH 4.6 IU/L (normal < 1.6), LH 0.5 IU/L (Normal < 0.1 ) 17 β- estradiol 25 (normal < 10).

  1. What is the likely diagnosis?
  2. What further investigations are required to confirm the diagnosis?
  3. Name 5 clinical pointers to differentiate true precocious puberty from premature thelarche.

Answer for stationS 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

10 weeks old male baby is admitted with seizures. Blood glucose at the time of admission was 22 mg/dl. He was treated with IV glucose infusion. Two subsequent blood glucose measurements are less than 30 mg/dl.

  1. What immediate management is required?
  2. What investigations are required at the time of hypoglycemia?
  3. Urine sample is negative for ketones. What could be the possible causes of hypoglycemia in this child? (Name two)
  4. The insulin level is 27 (normal 0-10). Describe further management options.

Answer for stationS 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

7 yr old girl from Delhi brought with her complaints of FTT, recurrent diarrhea, and pallor. Clinical examination reveals clubbing and generalized abdominal distension.

Investigations shows, Hb 7.8, PS shows Micro Hypo Anisocytosis, Serum albumin is 2.7 g/dl, Serum calcium is 7.7 mg/dl.

  1. Name 5 causes of chronic diarrhea and malabsorption in children
  2. Most probable diagnosis in this child?
  3. What serological tests may be useful?
  4. How to confirm the diagnosis?

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

An 8 mth old female infant. Referred for evaluation of large head size. She is the firstborn of second-degree consanguineous parents.
On examination, she has Macrocephaly, normal vision & hearing & normal neurological examination.

MRI brain revealed macrocephaly, dilated lateral ventricles, cortical atrophy & atrophy of striatum.

  1. What is the diagnosis?
  2. What special diet will you advise?
  3. What is the estimated average life span of this condition?

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

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

More OSCE Stations

  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

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