cnmc pediatric case study
DESCRIPTION
Major pediatric case study presentation on pediatric patient with uncontrolled type 1 diabetes. *Any identifying information has been removed to respect patient privacy*TRANSCRIPT
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TYPE 1 DIABETES Chandler Ray, Dietetic Intern
University of Maryland College Park January 31, 2014
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Outline• Type 1 Diabetes
• Nutrition and Type 1 Diabetes
• Case Study: Outpatient Center for Endocrinology & Diabetes Initial Assessment
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Type 1 Diabetes• Formally called “Insulin dependent, IDDM”• A chronic autoimmune disease in which the beta cells in the pancreas produce little or no insulin
• Insulin is a hormone that it needed to move blood sugar (glucose) into cells to store and use later for energy
• Results in glucose building up in the bloodstream (hyperglycemia)
• The body is unable to use the glucose for energy
Google Images Labeled for Re-use: http://upload.wikimedia.org/wikipedia/commons/8/8c/Pancreas_insulin_beta_cells.png
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Type 1 Diabetes • Characteristics of DM I
• 5-10% of all DM cases • Usually diagnosed <30 y/o • Onset not associated with diet or lifestyle • Requires insulin treatment for life
• Risk factors • Autoimmune (viral infections) • Genetic • Environmental (toxins)
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Type 1 Diabetes • Prior diagnosis: symptomatic hyperglycemia (wt loss) and/or
DKA • Criteria for diagnosis
• A1C > 6.5% or • FPG > 126 mg/dL (7.0 mml/L) or • 2-h plasma glucose > 200 mg/dL (11.1 mmol/L) during an OGTT or• In a patient with classic symptoms of hyperglycemia, a random plasma
glucose > 200 mg/dL (11.1 mmol/L)
Google Images Labeled for Re-use:http://pixabay.com/static/uploads/photo/2014/11/11/22/19/nurse-527615_640.jpg
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Signs/symptoms: Hyperglycemia: >126 mg/dL
- Polyuria - Polydipsia
- Polyphagia - Unintentional weight loss
- Fatigue/weakness - Blurred vision
Diabetic Ketoacidosis: ketones in the urine - Deep, rapid breathing - Nausea or vomiting
- Dry skin + mouth - Flushed face- Fruity breath - Stomach pain
Hypoglycemia <70 mg/dL- Shaking/sweating - Dizzines
- Fast heartbeat - Hunger
- Fatigue/weakness - Anxious/irritable
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Treatment: Exogenous Insulin • Types:
• Rapid-acting (insulin lispro [Humalog], insulin aspart [Novolog], and insulin glulisine [Apidra])
• Short-acting (insulin regular)• Intermediate-acting (insulin NPH)• Long-acting (insulin glargine [Lantus], insulin detemir [Levemir])
• Regimens • Classic Basal/Bolus *• Modified Basal/Bolus • NPH/Regular • 70/30 Mixture
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Nutrition and Type 1 Diabetes • Carbohydrates: Individualized for each patient/client
• Adjust food pattern in accordance with insulin requirement prescription
• Adjust insulin for physical activity • Intense therapy-counting CHO, adjusted for multiple injections
• Protein: typically recommend 1 serving with each meal
• Fat: ~30% of total kcals
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CHO Counting • Basic Carbohydrate Counting (poster)
• Identify CHO choices, learn choice groups• Using food labels • Design Meal Plan
• Advanced Carbohydrate Counting • Food record keeping • Monitor blood glucose patterns • Identify insulin: CHO ratio to become more flexible and develop
strategies to adjust medication, exercise, CHO intake
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Case Study
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Outpatient Nutrition Questionnaire
Patient Name: JC Age: 16 years-old Sex*: Male Race*: Caucasian
Reason for Visit: overweight/ uncontrolled type 1 diabetes
Activity: On high school cheerleading team (seasonal)
• Outpatient visit to Diabetes Clinic 1/21/15: Recent issues with diabetes management include difficulty with consistent blood sugar checks, missed insulin injections, and skipped meals. Previously seen on 11/7/2014 with a HbA1c of over 14%.
• Patient Goal: JC is interested in getting a drivers license, and therefore, is motivated to improve his glucose control and his monitoring frequency
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Background • PMH: Type 1 diabetes diagnosed in September 2011, Graves’ disease diagnosed at age 5, asthma, elevated blood pressure, microalbuminuria, bipolar disorder, depression, and anxiety.
• Birth history: 35 week ex-preemie, 2 weeks in NUCI for lung problems. Pregnancy complicated by Gestational DM in mother.
• Family history: Diabetes in maternal great-grandmother and maternal great-grandfather
• Social history: Admits to smoking cigarettes
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Mental Health • Depression• Bipolar Disorder• Anxiety• Binge Eating Disorder
• History of binging and purging
• Self-injury • Cutting on arms and legs • Suicide attempt
• Irregular sleep patterns
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Assessment • Nutrition Risk Level: Overweight/ uncontrolled type 1
diabetes/ binge eating disorder • Diet Order: Carbohydrate Controlled Diet + CHO counting
• Classic Basal Bolus Therapy: getting Lantus at a dose of 55 units at bedtime
• Carb ratio is 1:5 with a correction factor of 25.
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Diet History • Upon examination, pt presents with poor glucose control,
though A1c is slightly better than before
• Pt and mother report a “typical” day:• Breakfast is usually skipped because pt sleeps in late • Pt often forgets to pack a lunch so will grab something “on-the-go”
for lunch (i.e.: granola bar) • Skipped meals tend to lead to extreme hunger later on, as pt
reports excessive food intake throughout the evening hours while grazing late at night
• Claims to carbohydrate count at every meal
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Labs
Lab Normal Reference Range (no diabetes)
Target (diabetes)
1/21/15
Hemoglobin A1c <5.7% <7% 13.8%
14-day Average Blood Sugars
Less than 140 mg/dL(7.8 mmol/L)
150 Breakfast 303, lunch 397, dinner 287, bedtime 310
Blood Pressure Less than 120/80 mmHg
<120/80 125/75 mmHg
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Medications Medicine Function Possible-Nutrition Related Side
Effect
Novolog (insulin aspart) Fast-acting mealtime insulin Hypoglycemia (excessive hunger, nausea), hyperglycemia (increased thirst, weight loss), hypokalemia (dry mouth, increased thirst)
Lantus (insulin glargine)
Long-acting basal insulin Hypoglycemia, hyperglycemia, hypokalemia
Lisinopril ACE inhibitor Abdominal pain, diarrhea, nausea, vomiting, sore throat, loss of appetite
Levothyroxine
Thyroid hormone replacement Difficulty with swallowing, nausea, swelling of lips, throat, or tongue, diarrhea,
Lamictal
Anticonvulsant/ mood stabilizer Bloody stools, painful mouth sores, sore throat, trouble breathing, loss of appetite, or weight loss, dry mouth
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Weight for Age • Weight: 84.9 kg (187.2 lb)• 95th %ile• Z-score: 1.62
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Rate of Weight Change
Date of Measurement Weight Rate of weight change
January 29, 2014 86.8 kg --
February 14, 2014 85.5 kg -1.3 kg
April 16, 2014 88.3 kg +2.8 kg
May 20, 2014 87.0 kg -1.3 kg
July 23, 2014 83.9 kg -3.1 kg
November 22, 2014 84.0 kg +0.1
November 26, 2014 86.3 kg +2.3 kg
January 21, 2015 84.9 kg -1.3 kg
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Height for Age • Height: 180 cm (5’9’’ in)• 79 %ile• Z-score= 0.81
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BMI for Age • BMI: 26.2 kg/m2• 92%ile • Z-score= 1.40
Source: http://nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType=Metric
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PES Statement • NI-5.2.8 Excessive carbohydrate intake related to lack of
willingness/failure to modify carbohydrate intake as evidenced by average blood sugars 303, 397, 387, 310; Hemoglobin A1c 13.8%
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Estimated Requirements • Energy needs (kcals/kg): 2,500 Kcals per day (29.4 kcals/kg/day)
• Based on Mifflin St. Jeor (MSJ) using Actual Body Weight (ABW)
• Protein needs (Grams Protein/kg): 72.2 g PRO per day (0.85 grams protein/kg) • Based on DRI for Boys 14-18 years old
• Maintenance fluid needs (mL/day): 2,971.5 - 3396 ml (35-40 ml/kg)• Based on recommendations from Clinical Nutrition Pocket Guide for
Young Active 16-35 yo
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Recommendations • Continue carbohydrate counting • Recommend a normal eating schedule
• Pack a breakfast for on-the-go and pack lunch at night• Setting an alarm to take Levothyroxine in AM
• Limit consumption of sugary and carbohydrate-rich foods, especially late at night • Snacking on vegetables during the evening
• Monitor blood sugar checks (4x/day) and insulin injections • Reasonable weight loss goal
• 50-84%ile = 61.9kg (134lb)- 74.3kg (164lb) or • 75-84%ile given ED history = 70 (154lb)- 74.3kg (164lb)
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Plan/Goals
1) Use phone and mom as reminders for dinnertime insulin shots
2) Check blood sugar at breakfast, lunch, dinner, and nighttime
3) Eat 3 meals daily
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References • American Diabetes Asociation. Medical Management of Type 1 Diabetes. Alexandria, VA, American Diabetes Association, 2008. Web. 22 Jan. 2015.
• Appel, Lawrence J., Michael W. Brands, Njeri Karanja, Patricia J. Elmer, Frank M. Sacs. Dietary Approaches to Prevent and Treat Hypertension: A Scientific Statement From the American Heart Association.
• Barlow, S. E. "Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report." Pediatrics 120.Supplement (2007): S164-192. 22 Jan. 2015.
• "Bipolar Disorder | Anxiety and Depression Association of America, ADAA." ADAA, n.d. Web. 28 Jan. 2015.
• BMI Percentile Calculator for Child and Teen Metric Version. CDC, n.d. Web. 30 Jan. 2015. <http://nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType=Metric>.
• Board, A.D.A.M. Editorial. Graves Disease. U.S. National Library of Medicine, 10 May 2014. Web. 26 Jan. 2015.
• Clinical Nutrition Pocket Guide- MedStar Square Medical Center/ MedStar Harbor Hospital
• Diabetes - type 1 | University of Maryland Medical Center http://umm.edu/health/medical/reports/articles/diabetes-type-1#ixzz3PyIU7HcE
• Glucometer. Google Images Labeled for Re-use: http://pixabay.com/static/uploads/photo/2014/11/11/22/19/nurse-527615_640.jpg
• KDIGO. Chapter 1: Definition and classification of CKD. Kidney Int Suppl 2013; 3:19. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf 26 Jan. 2015.
• Lowry, Adam W., Kushal Y. Bhakta, and Pratip K. Nag. Texas Children's Hospital Handbook of Pediatrics and Neonatology. New York: McGraw-Hill, 2011. Print.
• Mahan, L. Kathleen., Sylvia Escott-Stump, and Janice L. Raymond. Krause's Food & the Nutrition Care Process. St. Louis (Miss.): Saunders, 2012. Print.
• Michigan Diabetes Research and Training Center. Diabetes Research, n.d. Web. 28 Jan. 2015. <http://www.med.umich.edu/borc/cores/ChemCore/hemoa1c.htm>.
• "Standards of Medical Care in Diabetes--2012." Diabetes Care35.Supplement_1 (2011): S11-63. Web. 22 Jan. 2015.
• Type 1 diabetes. Google Images Labeled for Re-use: http://upload.wikimedia.org/wikipedia/commons/8/8c/Pancreas_insulin_beta_cells.png
• Wu, Patricia, MD, FACE, FRCP. "Thyroid Disease and Diabetes." Thyroid Disease and Diabetes 18.I (2000): n. pag. Thyroid Disease and Diabetes. Web. 28 Jan. 2015.