Nutrition | PREP 2024

Divided by: Dr. Elaf AlShammari, Advanced General Pediatrics Fellow at NGHA, Riyadh

6 Questions | 16 pages

1 Scurvy
2 Mg Deficiency
3 Vitamin B12
4 Soy Formula
5 IDA
6 Milk Fortifier
AAP PREP 2024 - Question 171/267 Nutrition Question 1/6

An 8-year-old boy with autism is seen in the office. He developed a rash 1 week ago, and today he had
bleeding gums and is refusing to walk, stating that “it hurts.” The boy has not had prior issues with excessive
bleeding or any orthopedic issues. His diet is quite restrictive, limited to macaroni & cheese and chocolate
milk. His growth has been normal. The boy’s only medication is nightly guanfacine. The boy’s height and
weight are at the 75th percentile for age. He appears distressed and sits stiffly on the bed. He has a diffuse,
nonblanching rash (Figure). The remainder of his physical examination findings are unremarkable. Complete
blood count results are normal.

Rash for the child in the vignette.

Figure. Reprinted with permission from Nastro A, Rosenwasser N, Daniels SP, et al. Pediatrics, 2019;144 (3):
e20182824.

Of the following, the BEST treatment for this boy’s acute condition is to

A. administer fresh frozen plasma

B. administer vitamin C

C. administer vitamin K

D. prescribe a high-protein, high-calorie diet

Correct answer is B

PREP Pearl(s)
Scurvy can present with dramatic, subacute-onset disability due to bone pain.
Scurvy can be seen in children whose diets include normal caloric intake with minimal fresh fruits and
vegetables.
Scurvy is easily treated with vitamin C supplementation.

Critique
The boy in the vignette has scurvy (vitamin C deficiency) due to his restricted diet. The treatment for scurvy is
administration of vitamin C. In the past, scurvy was most commonly seen in sailors who often went many
months without access to fresh fruits and vegetables. So many foods in the United States are now fortified
with vitamin C that scurvy is quite rare in the general population. However, this deficiency can still be seen in
children whose diets are significantly limited either by behavioral or social issues. Scurvy can present with
dramatic, subacute-onset disability due to bone pain. Signs and symptoms of scurvy may include:

Fatigue
Easy bruising/petechiae
Gum bleeding
Bone pain
Myalgias
Perifollicular hemorrhages
Corkscrew hairs
Anemia
Poor wound healing

Untreated scurvy can have multi-organ complications (eg, jaundice, edema, neuropathy, seizures, hemolysis)
and can lead to death.

The treatment for symptomatic scurvy is intravenous or oral high-dose vitamin C 3 times daily for 1 week,
then daily vitamin C for 1 month. After that, if the child cannot or will not take a regular diet, a multivitamin
should be administered.

Blood levels of vitamin C increase quickly with supplementation, therefore a vitamin C level (usually sent to
an outside laboratory) should ideally be drawn before supplementation begins. Treatment should commence
immediately upon suspecting the diagnosis of scurvy (once the blood sample has been obtained for a vitamin
C level); it is not appropriate to wait for the vitamin C level result. High-dose vitamin C is a very low-risk and
inexpensive therapy.
Treatment with fresh frozen plasma would be recommended in the setting of acute bleeding due to vitamin K
deficiency, disseminated intravascular coagulation, or a specific factor deficiency. The child in the vignette’s
gum-bleeding does not meet that level of urgency. Administration of vitamin K would be indicated in the
setting of presumed or known vitamin K deficiency, such as a neonate who did not receive vitamin K
prophylaxis, or a child with liver failure or a fat-absorption deficiency.

A high-protein, high-calorie diet would not address this child’s symptomatic scurvy. The boy had been
consuming a diet that was providing adequate calories, as evidenced by his normal growth. Both milk and
cheese are protein sources, so likely he had adequate protein intake as well. However, this form of dietary
management would not address the boy’s vitamin C deficiency.

Suggested Reading(s)
Ceglie G, Macchiarulo G, Marchili MR, et al. Scurvy: still a threat in the well-fed first world? Arch Dis
Child. 2019;104(4):381-383. doi:10.1136/archdischild-2018-315496
Kothari P, Tate A, Adewumi A, Kinlin LM, Ritwik P. The risk for scurvy in children with
neurodevelopmental disorders. Spec Care Dentist. 2020;40(3):251-259. doi:10.1111/scd.12459
Likhitweerawong N, Boonchooduang N, Morakote W, Louthrenoo O. Scurvy mimicking as systemic
lupus erythematosus. BMJ Case Rep. 2021;14(6):e242958. doi:10.1136/bcr-2021-242958
Racine Ad. Failure to thrive: pediatric undernutrition. In: McInerny TK, Adam HM, Campbell DE, DeWitt
TG, Foy JM, Kamat DM, eds. American Academy of Pediatrics Textbook of Pediatric Care. American
Academy of Pediatrics; 2023. Accessed September 1, 2023. Pediatric Care Online

Content Domain
Nutrition

ABP Content Specification(s) / Content Area(s)

 Correlate clinical findings with a diagnosis of scurvy
Treat a patient with scurvy

The correct answer is: administer vitamin C

View Peer Results
AAP PREP 2024 - Question 172/267 Nutrition Question 2/6

A 12-year-old is undergoing a health supervision visit. She has been healthy overall and has not had concerns
regarding repeat infections. She was recently diagnosed with celiac disease and started a gluten-free diet.
Her parents report that for the past few weeks, she has had nausea and a decreased appetite and has felt
weak. They ask advice about additional diet changes or nutritional supplements that might help her. The
girl’s physical examination findings are normal. There are no changes in skin pigmentation or signs of
alopecia. Results of a complete blood cell count are normal for age.

Of the following, the nutritional deficiency MOST likely to explain this girl’s current symptoms is

A. copper

B. iron

C. magnesium

D. zinc

Correct answer is C

PREP Pearl(s)
Signs and symptoms of magnesium deficiency may include nausea, vomiting, and decreased energy or
weakness. More significant deficiencies are associated with muscle contractions or cramping, seizures,
numbness or tingling, mood instability, and, in severe cases, arrhythmias.
Signs and symptoms of copper deficiency may include hypopigmentation, anemia, connective tissue
disorders, and ataxia.
Zinc deficiency can lead to diarrhea, decreased growth, decreased appetite, and loss of the senses of
taste and smell. More severe deficiency can also lead to alopecia, skin manifestations (eg, perioral and
perirectal rash in infants), and frequent infections.

Critique
Of the response choices, magnesium is the nutritional deficiency most likely to explain this girl’s current
symptoms. A well-rounded diet, rich in nutrients and dietary minerals (eg, zinc, copper, and magnesium) is
important at all ages. Every 5 years, the US Department of Agriculture and US Department of Health and
Human Services publish Dietary Guidelines for Americans, a report of dietary recommendations based on the
most current data. The Table outlines the recommended daily intake of zinc, copper, and magnesium
according to age.

Magnesium is found in foods such as leafy greens, legumes, nuts, seeds, and whole grains. Processed grains
may lack this vital nutrient unless fortified (eg, fortified cereals). Only about 1% of the body's magnesium is
found in the blood, making the diagnosis of magnesium deficiency somewhat challenging. Most is stored in
the bone (50%-60%), with additional stores in the soft tissues. Urine magnesium levels, especially after
intravenous supplementation, may be helpful in identifying a deficiency (although this is controversial).

Symptoms of magnesium deficiency may include nausea, vomiting, decreased energy and weakness, as seen
in the girl in the vignette. More significant deficiencies are associated with muscle contractions or cramping,
seizures, numbness or tingling, mood instability, and, in severe cases, arrhythmias. Individuals at increased
risk of experiencing magnesium deficiency include those with the following factors:
 Increased urinary excretion secondary to loop diuretics (eg, furosemide)
Diabetes with poor glucose control, leading to glucosuria and increased urination (more
common in type 2 diabetes or insulin resistance)
Long-term (>12 months) treatment with proton pump inhibitors (decreased absorption, not
always improved with supplementation)
Malabsorption (eg, Crohn or celiac disease)

Excess magnesium intake, such as from laxatives with magnesium carbonate, chloride, or gluconate can lead
to diarrhea, owing to an inability to absorb the magnesium salts. Toxicity has been rarely reported with doses
of 5,000 mg/day; signs and symptoms include hypotension, flushing, urinary retention, lethargy progressing
to weakness, arrhythmia, and cardiac arrest.

Copper is found in foods such as shellfish, seeds and nuts, chocolate, and whole grains. Tap water and other
beverages are another source of copper, but with a wide content range (0.005 mg/L-1 mg/L). A large portion
of the body's copper is stored in skeletal muscle. The body achieves homeostasis by regulating absorption of
copper, as well as regulation by the liver of the amount excreted through bile. Symptoms of copper deficiency
include hypopigmentation, anemia, connective tissue disorders, and ataxia. Typical diets are rich in foods
with sufficient copper, and therefore deficiency is rare; however, children with certain conditions are at risk.
Celiac disease may cause impaired copper absorption, which may be improved with a gluten-free diet and
supplementation. A rare genetic disorder, Menkes disease causes impaired copper absorption, which leads
to failure to thrive, impaired cognition, and seizures. These children often have “kinky” hair. Treatment of this
disorder with subcutaneous copper supplementation within the first few weeks after birth leads to decreased
morbidity and mortality.
Signs and symptoms of copper toxicity include liver damage, abdominal pain, nausea, vomiting, and diarrhea.
Toxicity is uncommon other than in children with specific genetic disorders (eg, Wilson disease) or those with
excess exposure to copper from environmental factors (eg, copper leaching into drinking water from copper
plumbing).

Iron deficiency would present with anemia. Although weakness can be seen in individuals with iron deficiency
anemia, the girl in the vignette has a normal complete blood cell count.

Zinc is present in foods such as meat, fish, beans, whole grains, and fortified cereals. Beginning at age 6
months, infants should start receiving foods rich in zinc. This is especially important for those who are
breastfed. At the time of birth, breast milk is rich in zinc; however, the level of zinc decreases over the
following 6 months, regardless of maternal intake. Zinc is important for growth and immune function. Zinc
deficiency can lead to diarrhea, decreased growth, decreased appetite, and loss of the senses of taste and
smell. More severe deficiency can lead to alopecia, skin manifestations (eg, perioral and perirectal rash in
infants), and frequent infections.
Some conditions place children at increased risk of developing zinc deficiency, including genetic disorders
that result in a child’s having decreased absorption of zinc or a mother’s having low levels of zinc in her breast
milk. Children consuming a vegetarian diet can be at increased risk of experiencing zinc deficiency; the family
should meet with a nutritionist to review their diet and consider supplementation with a multivitamin, if
indicated.

Excessive zinc supplementation can be associated with decreased absorption of other nutrients (eg, copper
and magnesium) as well as toxicity. Symptoms of zinc toxicity include nausea, vomiting, dizziness, and
headache. Long-term exposure to high levels of zinc can result in lower levels of high-density cholesterol.

Suggested Reading(s)
Copper: fact sheet for health professionals. National Institutes of Health, Office of Dietary
Supplements. Accessed March 23, 2023. https://ods.od.nih.gov/factsheets/Copper-HealthProfessional/
Dietary Guidelines for Americans 2020-2025. US Department of Agriculture. Accessed February 22,
2023. https://www.dietaryguidelines.gov/sites/default/files/2020-
12/Dietary_Guidelines_for_Americans_2020-2025.pdf
 Kleinman RE, Greer FR, eds. Pediatric Nutrition. American Academy of Pediatrics; 2020. Accessed
February 22, 2023. Pediatric Nutrition Online
Magnesium: fact sheet for health professionals. National Institutes of Health, Office of Dietary
Supplements. Accessed March 23, 2023. https://ods.od.nih.gov/factsheets/Magnesium-
HealthProfessional/
Zinc: fact sheet for health professionals. National Institutes of Health, Office of Dietary Supplements.
Accessed March 23, 2023. https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

Content Domain
Nutrition

ABP Content Specification(s) / Content Area(s)

Understand the dietary mineral requirements of patients of various ages, including those born
prematurely, and the circumstances in which those requirements may change
Identify the conditions that are associated with a deficiency of various trace minerals (eg, zinc, copper,
magnesium, chromium)
The correct answer is: magnesium
View Peer Results

Table. Recommended Daily Intake of Zinc, Copper, and Magnesium,

According to Age.
Age Mineral
Zinc (mg) Copper (µg) Magnesium (mg)
0-6 months None available 200 30
7-11 months 3 200 75
12-23 months 3 340 80
2-3 years 3 340 80
4-8 years 5 440 130
9-13 years 8 700 240
14-18 years F, 9; M, 11 890 F, 360; M, 410
Pregnant 14-18 years 12 1,000 400
Postpartum 14-18 years 13 1,300 360
Abbreviations: F, female; M, male
Courtesy of J. Reed
AAP PREP 2024 - Question 173/267 Nutrition Question 3/6

An 8-year-old boy with autism is seen in the emergency department for evaluation of fatigue. For the past 3
days, his energy level and appetite have been reduced, and he has appeared pale. Today, he is sleepier than
usual. The boy has a severely limited diet owing to his food preferences. He typically eats cheese snack
crackers, peanut butter sandwiches on white bread, and cinnamon toaster pastries. He drinks apple juice
and water.
On physical examination, the boy is afebrile, his blood pressure is 95/47 mm Hg, his heart rate is 100
beats/min, and his respiratory rate is 16 breaths/min. His weight is 51 kg, his height is 149 cm, and his body
mass index is 23 kg/m2. He is interactive but appears fatigued. His mucous membranes are dry. He has
decreased deep tendon reflexes. His skin is pale and there is a 3-cm ecchymosis on his left shoulder. The
remainder of his physical examination findings are unremarkable.

Laboratory findings are shown:

Laboratory Test Result

White blood cell count 2,500/µL (2.50 × 109/L)

Hemoglobin 4.4 g/dL (44 g/L)

Mean corpuscular volume 99 fL

Platelet count 31 × 103/µL (31 × 109/L)

Sodium 136 mEq/L (136 mmol/L)

Potassium 4.0 mEq/L (4.0 mmol/L)

Chloride 99 mEq/L (99 mmol/L)

Bicarbonate 22 mEq/L (22 mmol/L)

Glucose 95 mg/dL (5.27 mmol/L)

Blood urea nitrogen 20 mg/dL (7.14 mmol/L)

Alkaline phosphatase 150 U/L

Creatinine 0.49 mg/dL (43.32 µmol/L)

Albumin 4.4 g/dL (44.00 g/L)

Phosphorus 4.6 mg/dL (1.49 mmol/L)

Magnesium 2.2 mg/dL (0.91 mmol/L)

Of the following, the MOST likely nutrient deficiency causing this boy’s findings is
 A. folate

B. vitamin B12

C. vitamin C

D. vitamin D

Correct answer is B

PREP Pearl(s)
Water-soluble vitamins (B complex, vitamin C) are absorbed in the small intestine and renally excreted.
Fat-soluble vitamins (A, D, E, K) are chylomicron dependent for absorption and stored in the liver and
adipose tissue.
Children with oral aversion, restrictive diets, fat malabsorption, and intestinal inflammation are at risk
of experiencing vitamin deficiencies.

Critique
The boy described in the vignette has a very limited diet and is at risk of experiencing nutritional deficiencies.
His pallor, fatigue, decreased deep tendon reflexes, macrocytic anemia, pancytopenia, and lack of animal
protein in his diet suggest vitamin B12 (cobalamin) deficiency.

Although folate deficiency can also cause macrocytic anemia, neurologic manifestations are not common. In
addition, many wheat-containing snack foods, which this boy eats, are fortified with folate. Vitamin C
deficiency can cause fatigue and easy bruising. However, the boy in the vignette drinks apple juice, which is
typically fortified with vitamin C, and he does not exhibit other suggestive findings (eg, bleeding gums).
Vitamin D deficiency is unlikely given the boy’s clinical presentation and normal calcium, phosphorus, and
alkaline phosphatase values.

Vitamin B12 is a water-soluble vitamin. Water-soluble vitamins (B complex, C) are easily absorbed in the small
intestine, metabolized, and then used or renally excreted. In contrast, fat-soluble vitamins (A, D, E, K) require
chylomicrons for intestinal absorption and are stored in the liver and adipose tissue. Table 1 reviews the
absorption, storage, and metabolism of water-soluble and fat-soluble vitamins.
It is important for practitioners to be aware of how various medical conditions can place children at risk of
experiencing nutritional deficiencies, as seen in the following examples:
Oral aversion or a restrictive diet increases the risk of experiencing a variety of nutritional
deficiencies (Table 2).
Difficulty with fat digestion (eg, pancreatic insufficiency or cholestasis) increases the risk of
experiencing fat-soluble vitamin deficiency.
Intestinal inflammation or having had an intestinal resection increases the risk of experiencing
nutritional deficiencies, determined by the region affected (eg, vitamin B12 deficiency in children
with ileal resection or severe ileal Crohn disease).

Suggested Reading(s)
Abali EE, Cline SD, Franklin DS, Viselli SM. Micronutrients: vitamins. In: Abali EE, Cline SD, Franklin DS,
Viselli SM, eds. Lippincott Illustrated Reviews: Biochemistry. 8th ed. Wolters Kluwer Health; 2021.
Diab L, Krebs NF. Vitamin excess and deficiency. Pediatr Rev. 2018;39(4):161-179. doi:10.1542/pir.2016-
0068
Sethuraman U. Vitamins. Pediatr Rev. 2006;27(2):44-55. doi:10.1542/pir.27-2-44
DeWitt TG. Vitamin D inadequacy. Point-of-Care Quick Reference. Pediatric Care Online. American
Academy of Pediatrics. December 29, 2020. Accessed September 1, 2023. Pediatric Care Online

Content Domain
 Nutrition

ABP Content Specification(s) / Content Area(s)

Understand the absorption, storage, and metabolism of fat- and water-soluble vitamins in patients of
various ages, including those born prematurely
The correct answer is: vitamin B12
View Peer Results

Table 1. Absorption, Storage, and Metabolism of Fat-Soluble and Water-Soluble Vitamins.

Vitamin Absorption Storage Metabolism Deficiency
Fat-Soluble Vitamins

Vitamin A (Retinol) Absorbed and esterified in intestinal Stored in the liver Hydrolyzed to retinol and transported out Blindness, follicular hyperkeratosis, impaired
cells to form retinyl esters; as retinyl esters of the liver with retinol binding protein growth, keratomalacia, nyctalopia, photophobia
chylomicron dependent
Vitamin D Absorbed in the small intestine, Stored in adipose Dietary vitamin D (D2 and D3) converted to Poor growth, rickets, tetany
chylomicron dependent; also tissue primarily 25-OH-D3 in the liver; then is metabolized
absorbed by skin to 1, 25-diOH-D3 in the kidney
Vitamin E Absorbed in the small intestine, Stored in liver Alpha-tocopherol binds to transfer protein Ataxia, double vision, hemolytic anemia, loss
(alpha-tocopherol) chylomicron dependent and low-density lipoprotein and secreted of deep tendon reflexes, muscle weakness,
into bloodstream sensory loss
Vitamin K Absorbed in jejunum; also produced Limited storage Metabolized in the liver to allow for Ecchymosis, hemorrhage, mucosal bleeding,
by intestinal bacteria (used rapidly) production of clotting factors petechiae, purpura
Water-Soluble Vitamins

B1 (thiamine) Absorbed in the small intestine Limited storage Converted by thiamine diphosphokinase Beriberi, fatigue, cardiac failure, polyneuritis,
enzyme to active form (thiamine Wernicke encephalopathy
pyrophosphate)
B2 (riboflavin) Absorbed in the proximal small Limited storage Enterocyte phosphatases convert dietary Blurring of vision, cheilosis
intestine riboflavin to free riboflavin
B3 (niacin) Absorbed easily in the small Limited storage Metabolized to NAD, NADPH Pellagra (rash, diarrhea, stomatitis, glossitis,
intestine (some in stomach) mental status changes)
B6 (pyridoxine) Absorbed rapidly by small intestine Limited storage Metabolized to pyridoxal phosphate Irritability, seizures, sensory ataxia

B9 (folate) Absorbed in the proximal small Limited storage Metabolized by dihydrofolate reductase to Macrocytic anemia, occasional pancytopenia,
intestine tetrahydrofolic acid irritability, failure to gain weight
B12 (cobalamin) Absorbed in the ileum when bound Stored in the liver Metabolized into coenzyme forms Ataxia, loss of deep tendon reflexes, macrocytic
by intrinsic factor anemia, occasional pancytopenia, sensory loss
C (ascorbic acid) Absorbed in the small intestine Limited storage Acts as a cofactor for many enzymes and Bone pain, joint swelling, mucosal bleeding,
hormones petechiae, poor wound healing, purpura, scurvy
NAD, nicotinamide adenine dinucleotide; NADPH, nicotinamide adenine dinucleotide phosphate.
chiectasis should be considered.

Table 2. Examples of Micronutrient Deficiencies Associated With

Selected Clinical Conditions
Condition Clinical Scenario Nutritional Deficiency
Restricted Vegetarian diet Vitamin B12
Diet
Highly restrictive diet Depends on the diet
(eg, autism, developmental Vitamins A, C
delay, food allergies)
Highly restrictive diet and Vitamin C
refusal to walk
Severe protein/energy Vitamin A, vitamin D, zinc, iron
malnutrition
Breastfed toddler with limited Iron, zinc
complementary food
Predominantly breastfed Vitamin D
infant or toddler, refusing to
walk; growth plateau
Exclusively breastfed newborn Vitamin K
with symptoms of bleeding or
altered mental status
Use of unfortified goat milk in Folate
infants with limited
complementary food
Chronic Obesity Vitamin D, iron
Condition
Cystic fibrosis Vitamins A, D, E, K (fat soluble), B12
Inflammatory bowel disease, Folate, vitamin B12, vitamins A, D, E,
short gut syndrome K (fat soluble), iron
Celiac disease Folate, vitamin B12, vitamins A, D, E,
K (fat soluble), iron, zinc
Acute Measles Vitamin A
Condition
Prolonged diarrhea Zinc
Medications Antacids Vitamin D, iron
Antiepileptic drugs Vitamin D
Corticosteroids Vitamin D
Methotrexate Folate
Sulfasalazine Folate
Trimethoprim Folate
Diab L, Krebs NF. Vitamin excess and deficiency. Pediatr Rev. 2018;39(4):164
AAP PREP 2024 - Question 174/267 Nutrition Question 4/6

A 2-month-old infant is undergoing a routine health supervision visit. He was born at 33 weeks’ gestation with
a birth weight of 3.96 lbs (1,800 g). He stayed in the neonatal intensive care unit for 12 days, requiring
positive airway pressure and oxygen support for the first 3 days after birth and phototherapy for
hyperbilirubinemia. He was fed cow milk–based premature infant formula via nasogastric tube for the first
few days and then orally. His discharge weight was 3.83 lbs (1,740 g). The infant’s mother recently switched
him to a soy protein-based formula owing to fussiness and “spitting up.” His weight today is 7.05 lbs (3,200 g),
and his physical examination findings are normal. The mother is counseled regarding the use of soy protein–
based formula for this infant.

Of the following, the BEST information to provide this infant’s mother is that the use of this formula

A. does not provide adequate minerals

B. is appropriate because of adequate weight gain

C. may help with colic and reflux

D. may help with cow milk protein allergy

Correct answer is A

PREP Pearl(s)
Premature infants require transitional or enriched formulas to provide adequate calories for growth
and minerals (calcium, magnesium, phosphorus) to prevent osteopenia.
The indications for soy protein–based formulas are galactosemia, congenital lactase deficiency, and
family preference for a vegan diet.
Soy protein–based formulas are not recommended for management of colic, gastroesophageal reflux,
or milk protein allergy.

Critique
Of the response choices, the best information to provide the mother of the preterm infant in the vignette is
that soy protein–based formula does not provide adequate minerals. Preterm infants have increased
requirements for calcium and phosphorus that are not met with a soy protein–based formula. Soy formulas
also contain increased concentrations of aluminum, which competes with calcium for absorption, leading to
further bone demineralization and contributing to osteopenia of prematurity.

This infant has had adequate weight gain (20-30 g/day) since discharge from the neonatal intensive care unit,
but he should remain on transitional formula at this time. Preterm infants are generally discharged from the
neonatal intensive care unit on enriched or transitional formulas (22 kcal/oz). In addition to a higher caloric
value, these formulas provide additional calcium, magnesium, and phosphorus, which is required to prevent
osteopenia. Transitional formulas are recommended for neonates born at 34 weeks’ gestation or earlier or
who have a discharge weight of more than 3.96 lbs (1,800 g), and are continued until age 6 to 9 months.

Standard soy protein–based formulas contain only 19 to 20 kcal/oz, which is less than what is recommended
for this infant. There is no evidence that soy protein–based formulas help with symptoms of colic or reflux.
Concern has been raised that high concentrations of phytoestrogens and isoflavones in soy protein–based
formulas can lead to estrogen-related adverse effects, but the evidence is inconclusive.
Nutritional requirements for healthy term and preterm infants are shown in the Table. These requirements
may be increased with specific medical conditions.

The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months after birth, followed
by the introduction of other foods with continued breastfeeding until at least age 1 year. Breastfeeding
provides health benefits to all infants, including those born prematurely, by protecting against infectious
diseases and reducing the risk of sudden infant death syndrome and future obesity. Parents may be unable
or elect not to breastfeed or may prefer a combination of breastfeeding and formula supplementation. There
are rare medical contraindications to breastfeeding (eg, galactosemia, maternal HIV infection).

The Infant Formula Act of 1980 ensures quality control of formulas by the US Food and Drug Administration.
Standard infant formulas have a caloric density of 19 to 20 kcal/oz and are available in powder, liquid
concentrate, and ready-to-feed formulations. Standard infant formulas contain cow milk as the protein
source, lactose as the carbohydrate, and a blend of vegetable oils as the fat source. As of 2002, most
standard formulas also contain long-chain polyunsaturated fatty acids.

The carbohydrate sources of soy protein–based formulas include glucose polymers, corn syrup, maltodextrin,
and sucrose. The fat source is a combination of vegetable oils. Indications for the use of soy formulas include
galactosemia, congenital lactase deficiency, and family preference for a vegan diet. Soy formulas are not
recommended for cow milk protein allergy owing to cross reactivity with soy in 5% to 15% of cases. Infants
with cow milk protein allergy can be treated with partially or extensively hydrolyzed cow milk protein
formulas (short-chain peptides and free amino acids) or elemental formulas (free amino acids).

Suggested Reading(s)
Milbrandt TP. Standard infant formula and formula feeding—cow milk protein formulas. Pediatr Rev.
2017;38(5):239-240. doi:10.1542/pir.2016-0211
Milbrandt TP. Specialized infant formulas. Pediatr Rev. 2017;38(5):241-242. doi:10.1542/pir.2016-0212
Stellwagen LM, Kim JH, Hurst NM. Optimizing nutrition for the preterm, very low-birth-weight infant
after discharge from neonatal intensive care. In: McInerny TK, Adam HM, Campbell DE, Foy JM, Kamat
DM, eds. American Academy of Pediatrics Textbook of Pediatric Care. 2nd ed. American Academy of
Pediatrics; 2016:chap 88. Accessed September 1, 2023. Pediatric Care Online

Content Domain
Nutrition

ABP Content Specification(s) / Content Area(s)

Know the content of various infant formulas and milk sources, the indications for their use, and
possible side effects
Understand the dietary fat requirements of patients of various ages, including those born prematurely,
and the circumstances in which those requirements may change

The correct answer is: does not provide adequate minerals

View Peer Results

Table. Nutritional Requirements for Healthy Term and Preterm

Infants.
Nutrient Nutritional Requirement
Term Infant Preterm Infant
Calories (kcal/kg/day) 95-110 110-130

Carbohydrate (g/kg/day) 9-10 11-13

Protein (g/kg/day) 1.5-2.2 2.5
Fat (g/kg/day) 4.5-5 5-6
Calcium (mg/day) 200 150-220

Phosphorous (mg/day) 100 75-140

Magnesium (mg/day) 30 8-15

Courtesy of S. Naganathan
AAP PREP 2024 - Question 175/267 Nutrition Question 5/6

A 3-month-old infant is seen in the office for a health supervision visit. The family has been struggling
financially. They have been unable to afford infant formula and have instead been giving the infant whole
cow milk.

Of the following, this infant’s diet puts them at greatest risk for

A. iron de ciency anemia

B. kidney injury

C. poor growth due to insufficient calories

D. vitamin D toxicity

Correct answer is A

PREP Pearl(s)
For families that are unable to or choose not to breastfeed, a cow milk protein (or soy-based protein
for a vegetarian diet) infant formula is considered an appropriate substitute.
The provision of pasteurized cow milk to infants younger than 12 months can result in iron deficiency
anemia due to poor absorption of iron and possible intestinal blood loss.
The level of iron is low in both human and cow milk but is highly bioavailable from human milk,
whereas bovine milk proteins are efficient inhibitors of iron absorption.

Critique
The infant in the vignette, being fed whole cow milk, is at greatest risk for iron deficiency anemia. The
American Academy of Pediatrics (AAP) recommends that infants exclusively breastfeed for the first 6 months
after birth and then continue breastfeeding with the addition of complementary foods for the second 6
months. For families that are unable to or choose not to breastfeed, a cow milk protein (or soy-based protein
for a vegetarian diet) infant formula is considered an appropriate substitute.

Cow milk protein formula typically contains approximately 40% more protein than breast milk, has a whey-
casein ratio that is more casein dominant (6-7 times the amount in human milk), and has higher
concentrations of the amino acids threonine, phenylamine, valine, and methionine. There are no known
clinical effects of this amino acid composition difference. The higher levels of casein in cow milk make it
harder to digest. Recently, infant formula products have become available with a whey-casein ratio that more
closely mimics human milk. Iron, a crucial component of cow milk protein formulas, is present at a
concentration of 12 mg/L.

The AAP recommends that pasteurized cow milk should only be provided to children after 12 months of age.
The provision of cow milk to infants has been associated with a number of nutritional deficiencies; it is most
strongly associated with iron deficiency anemia. The cause of this anemia is multifactorial. The level of iron is
low in both human and cow milk but is highly bioavailable from human milk, whereas bovine milk proteins
are efficient inhibitors of iron absorption. Approximately 50% of the available iron is absorbed from human
milk as opposed to 10% from cow milk. In addition, infant ingestion of pasteurized whole cow milk is
associated with occult intestinal blood loss; young infants can have nutritionally significant loss. The
significance and amount of occult intestinal blood loss decreases as an infant approaches 12 months of age.
Protein provides approximately 7% of the calories in human milk and 20% of the calories in cow milk.
Compared with human milk, whole cow milk has a lower content of zinc, niacin, and vitamins E and C. It also
has 3 times higher amounts of sodium and potassium, 4 times the amount of calcium, and 6 times the
amount of phosphorus. The higher protein, sodium, potassium, and phosphorus ratios increase the renal
solute load. However, there is no evidence that this causes kidney injury in healthy term infants.

The calorie content of whole cow milk is approximately equivalent to that in infant formula and human breast
milk. Cow milk does not cause vitamin D toxicity in infants.

Suggested Reading(s)
Hall RT, Carroll RE. Infant feeding. Pediatr Rev. 2000;21(6): 191–200. doi:10.1542/pir.21-6-191
Jiang T, Jeter JM, Nelson SE, et al. Intestinal blood loss during cow milk feeding in older infants:
quantitative measurements. Arch Pediatr Adolesc Med. 2000;154(7):673–678.
doi:10.1001/archpedi.154.7.673
Kleinman RE, Greer FR. Formula feeding of term infants. In: Kleinman RE, Greer FR, eds. Pediatric
Nutrition. 8th ed. American Academy of Pediatrics; 2020.
Leung AK, Sauve RS. Whole cow's milk in infancy. Paediatr Child Health. 2003;8(7):419-21.
doi:10.1093/pch/8.7.419
Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human
milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988

Content Domain
Nutrition

ABP Content Specification(s) / Content Area(s)

Identify the age-related changes in the ability to absorb and digest different nutrients relevant to infant
feeding
Understand the appropriate age at which cow milk should be introduced into the diet

The correct answer is: iron deficiency anemia

View Peer Results

AAP PREP 2024 - Question 176/267 Nutrition Question 6/6

A 7-day-old girl born at 28 weeks’ gestation with a birth weight of 1,250 g is transitioning from parenteral to
enteral nutrition using maternal breast milk with human milk fortifier. To maintain optimal growth, the
nutritionist is recommending preparation of the fortified breast milk to 24 kcal/oz.

Of the following, the condition this neonate should be MOST closely monitored for is

A. hypocalcemia

B. hypokalemia

C. hyponatremia

D. hypophosphatemia

Correct answer is C

PREP Pearl(s)
Preterm neonates have a higher energy requirement than those born at term.
The use of feedings supplemented with human milk fortifier can put a neonate at risk for
hyponatremia. Feedings concentrated to 27 kcal/kg/oz place the neonate at risk for hypercalcemia and
hyperphosphatemia.
Liquid human milk fortifier is preferred over the powdered form because of the greater risk of
bacterial contamination of powdered forms.

Critique
The use of a human milk fortifier (HMF) to increase the caloric value of breast milk puts the neonate in the
vignette at risk for hyponatremia due to the low sodium content of these feedings coupled with the increased
urine sodium losses seen in preterm neonates. For neonates who require high concentration feedings (>27
kcal/oz), there is an increased risk of hypercalcemia and hyperphosphatemia due to the mineral content of
this preparation. Potassium levels are not significantly affected by the addition of HMF. During the transition
to enteral feeds, routine monitoring of electrolytes is recommended until normal levels are stable and the
neonate is no longer receiving intravenous fluids or oral electrolyte supplements.

Term neonates require 100 to 120 kcal/kg/d for optimal growth, whereas preterm neonates require 100 to
150 kcal/kg/d. Healthy neonates require 40 to 60 kcal/kg/d to maintain their basal metabolic rate. Feeding,
digestion, elimination, and absorption require an additional 30 to 50 kcal/kg/d. Thermoregulation requires a
significant amount of energy; this requirement is even higher for preterm neonates with inadequate
subcutaneous fat stores. Those with conditions that increase metabolic demands (eg, lung disease,
congenital heart disease, and sepsis) have higher energy needs.

For preterm neonates, appropriate growth is critical for optimal neurodevelopmental outcomes. When
preterm neonates are ready for enteral feedings, it is essential to ensure that optimal calories, protein,
micronutrients, and electrolytes are provided. Growth charts designed specifically for preterm infants are
helpful to monitor for optimal growth (Figure).
 Reprinted with permission from Fenton TR, Kim JH. A systematic review and meta-analysis to revise the
Fenton growth chart for preterm infants. BMC Pediatrics. 2013,(13)59:7.

Figure. Fenton preterm growth chart for girls.

Current evidence supports the use of liquid HMF over powdered HMF because of the greater risk of bacterial
contamination of powdered products. Both human milk–derived and bovine milk–derived forms of liquid
HMF are available; evidence is currently insufficient to recommend one form over the other.

Suggested Reading(s)
Ben XM. Nutritional management of newborn infants: practical guidelines. World J Gastroenterol.
2008;14(40):61336139. doi:10.3748/wjg.14.6133
Carlson SJ, Ziegler EE. Feeding: NICU Handbook. University of Iowa Stead Family Children’s Hospital;
May 18, 2022. https://uihc.org/childrens/educational-resources/feeding-nicu-handbook
Schultz EV, Wagner CL. Powdered to liquid human milk fortifiers in the preterm infant. Neoreviews.
2021;22(6):e360-e369. doi:10.1542/neo.22-6-e360

Content Domain
Nutrition

ABP Content Specification(s) / Content Area(s)

Understand the caloric requirements for patients of various ages, including those born prematurely,
and the circumstances in which those requirements may change
Understand the nutritional supplements that can be used to increase caloric density of formulas and
their risks

The correct answer is: hyponatremia