Malnutrition and Nutritional Deficiencies (Vitamin Deficiencies, PEM) MCQs

Pediatrics · 59 free questions with answers & explanations.

  1. An 18-month-old child from a rural area presents with bilateral pitting edema up to the knees, sparse hypopigmented hair that plucks easily, a 'flaky paint' rash on the lower limbs, and marked irritability, but weight is relatively preserved. What is the MOST likely diagnosis?
  2. A 2-year-old child presents with bow legs, craniotabes, and widening of the wrists. Investigations show low serum calcium, low phosphate, elevated alkaline phosphatase, and a 'fraying and cupping' appearance of the distal radius metaphysis on X-ray. What is the MOST likely nutritional deficiency?
  3. A 4-year-old child in a tribal area presents with night blindness and Bitot's spots on the conjunctiva. Which of the following is the CORRECT dose of Vitamin A for treatment?
  4. A 10-month-old exclusively breastfed infant presents with irritability, refusal to bear weight, and subperiosteal hemorrhages on X-ray. Gum examination shows perifollicular hemorrhages. What is the DEFICIENCY?
  5. A wasted 2-year-old with severe acute malnutrition (SAM) is admitted. After ruling out medical complications, what is the MOST appropriate initial dietary approach?
  6. A 14-month-old child with severe acute malnutrition (SAM) is admitted with edema, miserable facies, skin changes, and weight-for-height Z-score < -3. On day 2 of therapeutic feeding with F-75 formula, the child develops worsening lethargy, bradycardia, and hypotension. Which electrolyte disturbance is MOST responsible?
  7. A 10-month-old exclusively breastfed infant whose mother is a strict vegetarian presents with failure to thrive, developmental regression, and megaloblastic anemia. Serum vitamin B12 is 80 pg/mL (normal >200 pg/mL). The MOST appropriate immediate management includes:
  8. A 3-year-old child from a rural area presents with bitot spots, night blindness, and corneal xerosis (X1B). According to the National Vitamin A Supplementation Programme, which dose should this child have received MOST RECENTLY?
  9. A 2-year-old child presents with bowing of legs, widened wrists with cupping and fraying on X-ray, and a serum calcium of 8.0 mg/dL, phosphate 2.5 mg/dL, alkaline phosphatase 600 IU/L, and 25-OH Vitamin D level of 8 ng/mL. The MOST appropriate treatment is:
  10. A 6-year-old child is classified as 'moderate acute malnutrition' (MAM) with MUAC 11.8 cm and weight-for-height Z-score -2.5 to -3 without edema. According to India's POSHAN 2.0 programme, which intervention is MOST appropriate?
  11. A 2-year-old child with severe acute malnutrition (SAM) presenting with edema, severe wasting, and miserable demeanor is admitted. On admission, blood glucose is 42 mg/dL. Which of the following is the most important initial intervention to prevent mortality?
  12. A 9-month-old exclusively breastfed infant from a vegetarian family presents with developmental regression, hypotonia, and macrocytic anemia. Serum B12 is 80 pg/mL (normal > 200). Which of the following correctly identifies the mechanism of neurological damage in vitamin B12 deficiency?
  13. A 3-year-old child presents with irritability, a 'sunset sign' (eyes forced downward), and enlarging head circumference. Fontanelle is tense. MRI shows periventricular T2 signal changes and ventricular enlargement. Vitamin A level is elevated (hypervitaminosis A). Which of the following is a correct pathophysiological link between hypervitaminosis A and raised intracranial pressure?
  14. A 15-month-old child presents with 'rachitic rosary', widened wrists, delayed dentition, and muscle hypotonia. X-ray shows cupped, frayed metaphyses and widened growth plates. Serum findings: calcium 7.5 mg/dL, phosphorus 2.8 mg/dL, ALP 900 U/L, 25-OH vitamin D 8 ng/mL. Which statement best differentiates nutritional rickets from X-linked hypophosphatemic rickets (XLH)?
  15. A 2-year-old child with severe acute malnutrition (SAM) is admitted. On day 2, blood glucose drops to 35 mg/dL and child becomes hypothermic (temperature 35.2°C). According to WHO 10-step protocol for SAM management, which electrolyte abnormality is most dangerous during the first week (refeeding phase)?
  16. A 6-month-old exclusively breastfed infant presents with generalized seizures. Serum calcium is 6.8 mg/dL with markedly elevated alkaline phosphatase. Serum 25-OH Vitamin D is undetectable. The most likely clinical syndrome and its mechanism is:
  17. A child with kwashiorkor is distinguished from marasmus most reliably by which single pathophysiological feature?
  18. A 2-year-old child with severe acute malnutrition (SAM) is admitted with bilateral pitting pedal edema, skin lesions, and a miserable affect. Weight-for-height is -3 SD. On day 2 of treatment with F-75, the child develops bradycardia, prolonged QT interval on ECG, and muscle weakness. Which electrolyte abnormality is MOST responsible?
  19. A 4-month-old exclusively breastfed infant (no sunlight exposure) presents with convulsions. Serum calcium is 6.5 mg/dL, phosphorus is 5.8 mg/dL, and serum 25(OH)D is undetectable. What is the MECHANISM of hypocalcemia in this case?
  20. A 2-year-old boy has a diet consisting mainly of polished rice and is brought with dermatitis symmetrically distributed on sun-exposed areas, diarrhea, and dementia. Urine shows elevated 5-hydroxy indole acetic acid. What vitamin deficiency is RESPONSIBLE, and what is the BIOCHEMICAL basis?
  21. A 6-month-old infant with SAM classified as marasmus is brought for treatment. Which therapeutic milk formula should be initiated in the STABILIZATION phase (first 1–7 days)?
  22. A 2-year-old child with severe acute malnutrition (SAM) is admitted to a facility. Weight for height is -4 SD. The child has no pedal edema and a good appetite. According to WHO/IAP SAM management protocol, this child is BEST managed with:
  23. A 9-month-old exclusively breastfed infant presents with irritability, reluctance to move the right leg, and subperiosteal hemorrhages on X-ray. Serum alkaline phosphatase is elevated. Serum vitamin C is low. The diagnosis is scurvy. Which clinical sign is pathognomonic of infantile scurvy (Barlow's disease)?
  24. A 14-month-old child from a low-income family presents with pallor, angular stomatitis, cheilosis, and a smooth, glossy tongue. Hemoglobin is 7.2 g/dL, MCV 65 fL, serum ferritin 4 ng/mL, and serum folate is low. The peripheral smear shows microcytes and hypersegmented neutrophils. What is the MOST likely explanation for this combined deficiency?
  25. A 2-year-old child with severe acute malnutrition (SAM) is admitted with bilateral pitting oedema to the knees, sparse reddish-brown hair, and hepatomegaly. Blood glucose is 2.1 mmol/L. On day 2, the child develops diarrhoea, and the team decides to give ready-to-use therapeutic food (RUTF). Which electrolyte is SPECIFICALLY low in kwashiorkor and predisposes to potentially fatal arrhythmias during refeeding?
  26. A 7-month-old exclusively breastfed infant presents with irritability, refused to bear weight on one limb, and periosteal reaction of the femur and tibia on X-ray. Alkaline phosphatase is elevated and serum phosphorus is low. Mother is a dark-skinned immigrant who wears full-body covering clothing. The pathophysiology of the bone disease involves:
  27. A 15-month-old child has received only breast milk since birth. He has pallor, a smooth beefy-red tongue, and absent deep tendon reflexes in both lower limbs. Peripheral smear shows macro-ovalocytes and hypersegmented neutrophils. Serum B12 is 65 pg/mL (normal >200). Which finding would MOST help differentiate neurological manifestations of B12 deficiency from folate deficiency?
  28. A 2-year-old child with severe acute malnutrition (SAM) and bilateral pitting edema is admitted. On day 2 of re-feeding, he develops rapid heart rate, respiratory distress, and altered consciousness. His serum potassium drops to 2.8 mEq/L and phosphorus to 1.1 mg/dL. What is the MOST likely complication, and what is the key pathophysiology?
  29. A 14-month-old infant exclusively breastfed by a vegan mother presents with hypotonia, developmental regression, pallor, and a large tongue. CBC shows macrocytic anemia (MCV 112 fL). Serum B12 is 68 pg/mL (normal >200). Homocysteine is markedly elevated. What is the explanation for B12 deficiency in this breastfed infant?
  30. A 3-year-old presents with bone pain, bowing of legs, widening of wrists, and frontal bossing. X-ray shows widening and fraying of the metaphysis, cupped ends, and Looser's zones. 25-OH vitamin D is 8 ng/mL. His diet is vegetarian, and he has minimal sun exposure. TRAP (tartrate-resistant acid phosphatase) staining on a bone biopsy, if done, would show increased osteoclast activity. What additional electrolyte finding confirms vitamin D-deficient rickets rather than hypophosphatemic rickets?
  31. A 2-year-old child with severe acute malnutrition (SAM) presents with bipedal pitting edema, skin changes (flaky paint dermatosis), and irritability. On admission, blood glucose is 1.8 mmol/L. After 10% glucose (5 mL/kg IV over 15 minutes), the next step in management per WHO/UNICEF guidelines is:
  32. A 10-month-old exclusively breastfed infant presents with irritability, craniotabes, and wrist widening on physical examination. X-ray shows cupping and fraying of metaphyses. Serum calcium is 8.1 mg/dL, phosphorus 3.2 mg/dL, alkaline phosphatase markedly elevated, 25-OH Vitamin D level is 12 ng/mL. The single most important biochemical marker that reflects the ACTIVE SEVERITY of the disease process (not just deficiency status) is:
  33. A 3-year-old child presents with follicular hyperkeratosis (goose-flesh skin), perifollicular hemorrhages, and bleeding gums. The mother reports very poor consumption of fresh fruits and vegetables. The deficient nutrient is involved in which enzymatic reaction that explains the perifollicular hemorrhages?
  34. A 6-month-old infant's growth is assessed. Birth weight was 3.2 kg. Current weight is 5.9 kg. Weight-for-age z-score is -2.3 (moderate underweight). However, the child appears energetic, has appropriate length for age (LAZ 0), and MUAC is 12.5 cm. The MOST APPROPRIATE classification of nutritional status in this child is:
  35. A 9-year-old child from a slum community presents with bilateral bowing of legs. X-rays show widened growth plates, cupped metaphyses, and cortical thinning. Serum calcium and phosphorus are both low, ALP is very high, PTH is elevated, and 25-OH vitamin D is undetectable. In addition to Vitamin D supplementation, which OTHER micronutrient is essential to co-administer to prevent hypocalcemic tetany and promote bone mineralisation?
  36. A 2-year-old child from a rural area presents with severe acute malnutrition (SAM) with bilateral pitting pedal edema, sparse reddish discoloration of hair, and a miserable affect. Serum albumin is 1.8 g/dL. Which electrolyte disturbance is the MOST DANGEROUS and requires careful correction in this child?
  37. A 14-month-old child exclusively breastfed without vitamin D supplementation presents with bowing of legs, rachitic rosary, and hypocalcemic seizures. Biochemistry: serum calcium 7.2 mg/dL, phosphorus 2.1 mg/dL, ALP 890 IU/L, PTH elevated. Which radiological finding at the wrist is MOST specific for active rickets?
  38. A 10-month-old infant on cow's milk formula (unmodified) and no solid foods presents with pallor and irritability. CBC shows Hb 7.1 g/dL, MCV 62 fL, MCH 19 pg, serum ferritin 4 ng/mL, serum iron 28 μg/dL. Serum lead level is normal. What is the PRINCIPAL mechanism by which unmodified cow's milk causes iron deficiency anemia in infants?
  39. A severely malnourished child admitted for therapeutic feeding develops sudden clinical deterioration with abdominal distension, hypothermia, bradycardia, and hypoglycaemia during the first 48 hours of management. What is the most likely cause?
  40. A 9-month-old breastfed infant from a strictly vegetarian family presents with pallor, irritability, poor feeding, and regression of motor milestones. Blood smear shows macrocytic anaemia. Serum B12 is 88 pg/mL (normal >200). Which feature would be MOST characteristic on neurological examination?
  41. In Severe Acute Malnutrition (SAM), the WHO criteria for inpatient admission include which of the following weight-for-height (WFH) thresholds?
  42. A 2-year-old is admitted with SAM (severe acute malnutrition) — weight for height z-score −3.5, bilateral pitting pedal edema, and sparse reddish hair. He develops fever 48 hours post-admission with no localizing signs. C-reactive protein is elevated. The MOST appropriate antibiotic approach for this child per WHO SAM management protocol is:
  43. A 3-year-old has Bitot's spots on the temporal bulbar conjunctiva, night blindness, and a dry, rough skin. Serum retinol is 0.18 µmol/L (normal >0.70). Per WHO protocol for clinical vitamin A deficiency in a child aged 12–59 months, the CORRECT treatment dose on Days 1, 2, and 14 is:
  44. A 2-year-old child from a food-insecure household presents with marked oedema of the face and lower limbs, hepatomegaly with fatty change, apathy, sparse depigmented hair (flag sign), and flaky paint dermatosis. Weight for age is 65% of expected. Serum albumin is 1.8 g/dL. What is the immediate therapeutic priority after resuscitation?
  45. A 15-month-old child exclusively breastfed beyond 6 months without complementary feeds presents with bowing of both legs, a rachitic rosary, and widening of the wrist metaphyses. Calcium is low, phosphate is low, ALP is markedly elevated, and PTH is elevated. 25-OH vitamin D is 7 ng/mL. Which radiological finding is MOST characteristic of nutritional rickets?
  46. A 2-year-old severely malnourished child with bilateral pitting edema, skin changes, and hair depigmentation is being treated for Kwashiorkor. On day 3 of treatment, he develops persistent hypoglycemia, hypothermia, and bradycardia despite glucose supplementation. What is the MOST likely complication responsible for this clinical deterioration?
  47. A 9-month-old breastfed infant from a strictly vegetarian family presents with hypotonia, developmental regression (loss of previously achieved milestones), megaloblastic anemia, and elevated homocysteine. Serum B12 is <100 pg/mL. What is the MECHANISM of neurological damage in vitamin B12 deficiency?
  48. A 2-year-old child with severe acute malnutrition (SAM) weighing 7 kg (expected 12 kg) is admitted with bilateral pitting edema, generalized skin hyperpigmentation with 'flaky paint' desquamation, sparse, reddish, easily pluckable hair, and hepatomegaly. He is conscious but apathetic. Serum albumin is 1.4 g/dL. Which is the most dangerous complication to anticipate during refeeding?
  49. A 9-month-old exclusively breastfed infant of a strict vegan mother presents with developmental regression (lost social smile, decreased head control), hypotonia, megaloblastic anemia, and methylmalonic aciduria. Serum vitamin B12 is undetectable. What is the primary mechanism of neurological damage in this infant?
  50. A 2-year-old from a rural area presents with weight 7 kg (expected ~12 kg), bilateral pitting edema up to the knees, sparse reddish hair, and a 'flaky paint' dermatosis with areas of hyperpigmentation and desquamation. Serum albumin is 1.6 g/dL. The diagnosis is:
  51. A 10-month-old exclusively breastfed infant from a strict vegetarian family presents with pallor, developmental regression, hypotonia, and macrocytic anemia (Hb 7.2 g/dL, MCV 108 fL). Serum B12 is critically low at 58 pg/mL. The MOST likely mechanism of B12 deficiency in this breastfed infant is:
  52. A 6-year-old child from a low-income household presents with bilateral painful swelling of the wrists, tender subperiosteal hemorrhages over the tibia, perifollicular hemorrhages on the skin, and bleeding gums with loose teeth. The diagnosis and deficient vitamin is:
  53. A 3-year-old boy from a remote area presents with bilateral pitting edema up to the thighs, skin peeling (flaky-paint dermatosis), depigmented hair (flag sign), hepatomegaly, and irritability/apathy. Weight-for-height z-score is −3. His serum albumin is 1.6 g/dL. According to the WHO F-75/F-100 rehabilitation protocol, what is the CORRECT first 48-hour management priority?
  54. A 9-month-old exclusively breastfed infant presents with pallor, irritability, and hypotonia. Hb is 7.2 g/dL, MCV 59 fL, serum ferritin 4 ng/mL. Mother's dietary history shows no red meat, poultry, or iron-rich foods. Which mechanism BEST explains why exclusive breastfeeding beyond 6 months without complementary feeding leads to iron deficiency?
  55. A 2-year-old child with severe acute malnutrition (SAM, marasmus type) is admitted. On day 2, he develops bradycardia, QTc prolongation, and muscle cramps. The electrolyte most likely responsible and the corrective step is:
  56. A 9-month-old exclusively breastfed infant from a vegan family presents with pallor, hypotonia, regression of milestones, macroglossia, and megaloblastic anemia. The diagnosis and the mechanism is:
  57. In kwashiorkor, the pitting edema is specifically described as 'flaky paint dermatosis' on the skin. The primary pathogenesis of edema in kwashiorkor (compared to marasmus) is:
  58. During rehabilitation of a severely malnourished child (Kwashiorkor), the child develops sudden profound weakness, bradycardia and cardiac arrhythmia on day 3 of feeding. The most likely metabolic cause is:
  59. A 9-month-old infant exclusively breastfed by a strictly vegan mother presents with megaloblastic anemia, irritability, hypotonia and a developmental regression. Serum folate is normal, serum B12 is extremely low. The mechanism of neurological damage in B12 deficiency is:
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