Scenario 1

A baby boy born at term with a birth weight of 3.2 kg was growing along the median. At 3 months
of age mother had to go back to work as her maternity leave was over. She is a teacher and stays
in the school quarters. She gets to leave school one hour early to feed the baby.
a. This mother seeks your advice on feeding her child as her maternity leave is over. What
feeding advice will you give?
The weight which was measured at 4 months of age, when he came for vaccination to the MOH
clinic showed growth faltering, where the child was 200 g below the median.
b. What advice would you give the mother?
Child is now one year of age and is fed on a mixed diet. He is given food after blending into a
thick liquid preparation. Child is fed on breast milk on demand. Child was brought to the clinic
stating that child is not eating. Weight measurement shows that the weight is static over the last 3
months. Mother complains that child has a poor appetite and also child vomits whenever food
particle are given to her.
c. How would you advice the mother on feeding this child?

Scenario 2
An 11 year old child is brought to the OPD for recurrent wheezing. His height is 135cm (+2 to -2
SD) and weight is 45kg. BMI is 24.7 kgm-2 (>85th centile).
Child was born at term with a birth weight of 2.3 kg. He initially grew along the standard deviation
line but after 9 months of age, his weight curve moved up crossing the standard deviation lines,
after the introduction of formula milk.
Mother had gestational diabetes which was controlled on diet and paternal grandmother is a
diabetic on oral hypoglycaemic medications. Apart from treating for the asthma, child was
evaluated for obesity. Child had acanthosis around the neck while the other systems were clinically
normal.
Dietary history revealed that he does not take food at home but drinks a glass of milk after eating
4 biscuits. On the way to school he eats a bun and during the school interval he eats a sausage bun
from the canteen with a packet of sweetened milk. Once he returns from school he takes a big rice
meal and then around 4 pm he eats a packet of biscuits of about 10-15 with a glass of milk. For
dinner he eats rice or noodles or any other food that is usually bought from outside.
a. List this childs medical problems.

b. List the aetiological factors responsible for the medical problems in this child.
c. What is the feeding advice you would give these childs parents.

Scenario 3
A 6 year old boy is newly diagnosed to have nephritic syndrome. Serum albumin is 2.1 g/dl and
cholesterol is 460mg/L. Child has gross oedema but has a satisfactory urine output. He was given
intravenous albumin and is started on oral prednisolone.
a. Outline the dietary advice that you would give this child and parents during the acute
phase of the illness
The childs oedema and proteinuria settled and went into remission. The child is now started on
oral prednisolone 40 mg daily for the next 6 weeks and is about to be discharged.
Mother is concerned that prednisolone would increase the childs appetite and make her obese.
b. How would you advice this mother.

Scenario 4
A 5 month old baby with congenital heart disease is awaiting corrective surgery. Childs birth
weight was 2.8kg and current weight is 3.7kg. Child is in heart failure which is satisfactorily
controlled by diuretics. As child was feeding very poorly it was decided to start on naso gastric
tube feeding.
a. How would you commence naso gastric feeding?
b. Outline how you would feed this child through the naso gastric tube.
c. Outline the management of under-nutrition of this child.
After 7 days of management the child had gained only about 10g per day on average and was
vomiting the feeds immediately after the full naso gastric feed.
d. What are the reasons for poor weight gain in this child?
e. How would you change the management of this child?

Scenario 5
A 9 month old baby was brought to the clinic as she was not walking yet. She was born at term
with a birth weight of 3kg. She was treated for dehydration fever and received phototherapy for
one day prior to discharge from the postnatal ward.
On developmental assessment she was able to sit without support and crawl but was unable to
stand with support. She could transfer objects but did not demonstrate mature pincer grasp. She
had a polysyllable babble, stranger anxiety and object permanence.
a. Determine the developmental ages for the 5 different domains in this child, giving
reasons.
b. Compare the developmental ages with the chronological age and determine the presence
or absence of a developmental delay
c. Considering the above, outline the principles of management.
Scenario 6
A 6 month old baby was brought to the clinic as the mother was concerned that he was not sitting.
This baby was born at 32 weeks gestation with a birth weight of 1.2kg and was exclusive breast
fed.
He continued to grow along his birth centile and his growth curve was parallel to the -3SD line but
remained below it in the red zone. The midwife has advised the mother to start formula feeds as
the child was not growing enough on breast milk alone.
Baby had good head control and could not sit with support. Baby demonstrated hand play and was
trying to reach out but had overshooting and could not get the object. He vocalized and got excited
when seeing the mother approach. He pats at his mirror image and gets excited when he is shown
a new object but does not care if it is taken away from his line of vision.
a. Comment on the growth of this child.
b. Do you agree with the midwife? Give reasons for your answer.
c. Outline the feeding advice you would give this mother.
d. Determine the developmental ages for the 5 different domains in this child, giving
reasons.
e. What is the corrected gestational age of this child?
f. What is the difference between the chronological age and the corrected gestational age?

g. Which one of the above would you expect to correlate better with his developmental age?
h. Considering the above determine the presence or absence of a developmental delay
giving reasons.
i.

Outline the principles of management.

Scenario 7
A 2 year old child was carried into the clinic as he could not walk. He was born at term with a
birth weight of 4kg and had not cried at birth. He was the elder child of a poorly controlled diabetic
mother, who was single and unemployed. He was ventilated in the neonatal unit for one week and
was discharged on anti-convulsants and nasogastric feeds.
He could sit without support but could not stand or walk. He reached out and got objects but could
not transfer from hand to hand. He had a monosyllable babble but did not say any words. He had
no stranger anxiety nor object permanence. He had a social smile and reacted to new toys.
a. Determine the developmental ages for the 5 different domains in this child, giving
reasons.
b. Compare the developmental ages with the chronological age and determine the presence
or absence of a developmental delay.
c. Considering the above, outline the principles of management.
d. Describe the community services available to this family in Sri Lanka and how you
would facilitate this family to obtain these services.