Pediatric Nutrition Internship

Pediatric Nutrition InternshipIntern: Chandler Ray

Pediatric Written Case Study

Subjective:1. Physical Appearance: Pt is a 16 yo M diagnosed with type 1 diabetes since September 2011 with a h.o poor glycemic control and non-compliance with insulin. Upon initial assessment, pt was a well appearing pleasant young man, normally nourished.

2. Diet History prior to admissiona. Feeding History: Pt has been carbohydrate counting at mealtime. Pt often skips breakfast, eats a reasonably light lunch and then eats what he describes to be quite a bit of food or too much food in the afternoon and evening hours. b. Method of feeding: Oral intake with no history of chewing and/or swallowing difficulties.c. Oral/Enteral Intake Specific formula: n/a- pt is not formula fed Mixing procedures: n/a- (see above) Caloric density: n/a- (see above) Schedule: Pt admits to having some issues with his sleep pattern, which sometimes results in missing his Lantus dose at nighttime. Per mother, JC will sleep till between 11 AM and 1 PM on the weekends and not wake up early to check his blood sugar. Fluid flushes: n/a- pt is not receiving fluid flushes. WIC: n/a- family does not use WIC 24-hour recall or typical day: PTA, pt would usually skip breakfast and grab sometime small for lunch, such as a sandwich or a granola bar. Typically, pt is starving by the time he gets home from school and reports excessive food intake while grazing late at night. Tolerance issues: pt denies any tolerance issues, including nausea/vomiting/ diarrhea/constipation. Any other relevant information: Pt has a h.o an eating disorder, admits that food is sometimes an addiction to him and binge eats, especially late at night. Pt has not purged since about September of 2013. Additionally, pt has a h.o bipolar disorder, depression, anxiety, and self-injury. Pt does endorse a history of suicide attempt in October 2013, involving an overdose of insulin, 40 units. Admit to smoking cigarettes. d. Vitamin or Mineral Supplements: n/a- pt denies taking any vitamin or mineral supplements. e. Food Allergies: n/a- pt has no known food allergies.

PES:

1. Nutrition-related diagnosis: NI-5.2.8 Excessive carbohydrate intake related to lack of willingness to modify carbohydrate intake and excessive food intake while grazing late at night as evidenced by average blood sugars 303, 397, 387, 310 and A1c of 13.8%

a. Justify nutritional significance: Pt known to skip meals frequently, which tends to lead to extreme hunger and excessive intake of carbohydrate-rich foods at nighttime, increasing his risk for hyperglycemia. As a result of pts poor glycemic control, he consistently has high blood sugar levels and an elevated hemoglobin A1c (HbA1c). b. Give brief of natural history of the diagnosis: Pt has a known h.o of type 1 diabetes diagnosed in September 2011, as well as Graves disease diagnosed at 5 years of age, currently on thyroid replacement therapy. Additionally, pt has a h.o of elevated blood pressure, asthma, and microabluminuria. A combination of pts mental health disorders (bipolar disorder, depression, & anxiety) has likely contributed to the development of his eating disorder. These illnesses have been associated with irregular sleeping patterns, significant change in appetite, psychosis, suicidal thinking, and periods of sadness and hopelessness. Pt is overweight, as he frequently binges throughout the night and makes poor food choices. JCs poor control and inadequate testing has restricted him from driving independently. 2. Diet Order: Carbohydrate Controlled Diet + CHO counting a. On Classic Basal Bolus Therapy: getting Lantus at a dose of 55 units at bedtimeb. Carb ratio is 1:5 with a correction factor of 25. 3. Age: 16 yo a. Corrected Age: n/a- Corrected age corrects for a babys prematurity, also known as adjusted age or post conceptual age.b. Justify use of corrected age: n/a 4. Weight: 84.9 kg (187.2 lb)a. Percentile: 95th%ileb. Corrected weight percentile: n/ac. Weight age: 61.9 kg (50th %ile) 5. Height: 180 cm (70.9 in)a. Percentile: 79 %ileb. Corrected height percentile: n/a c. Height age: 174 cm (50th %ile) 6. Head Circumference: n/a- the WHO head circumference-for-age charts and tables are from birth to 5 years of age. Measurement is typically taken with childrenages0-3 years old.a. Percentile: n/a b. Corrected head circumference percentile: n/a c. Head circumference age: n/a 7. Weight/Height Percentile: n/a- Weight/Height %ile is used in place of BMI for children under 2 years of age when BMI is not appropriate a. Justify rationale for use of this number: n/a 8. Body Mass Index/percentile: 26.2 kg/m2 / 92%ile9. Plot patient on growth chart

a. Justify choice of growth chart: I choose to plot JCs growth using the CDC growth charts: Stature-for-age, Weight-for-age and BMI-for-age for boys 2 to 20 years of age. The CDC growth charts are used for children ages two years and older in the U.S., whereas, the WHO growth standards are to monitor growth for infants and children ages 0 to 2 years of age in the U.S.b. Evaluate patients growth: JCs BMI-for-age places himat the 91st percentilefor boys ages 16 years. This means JC is overweight. According to the CDC BMI-for-age growth chart, overweight is any 85thto less than the 95thpercentile. A healthy weight for JC would be between the 5thpercentile and up to the 85thpercentile.

10. Estimated Requirementsa. Energy Needs: Kcals/kg: 29.4 kcals/kgb. Protein Needs: Grams Protein/kg: 0.85 grams protein/kg c. Maintenance fluid needs mL/day: 2,971.5 3396 mld. Justify how you determined these numbersi. Mifflin St. Jeor (MSJ) based on Actual Body Weight (ABW):Men: REE= [9.99 X wt (kg)] + [6.25 X ht (cm)] [4.92 X age] + 5 Men: REE = [9.99 X 84.9 kg] + [6.25 X 180 cm] [4.92 X 16] + 5 REE= 848.2 kg + 1125 cm 78.7 + 5 = 1754.2 kcalsREE= 1899.5 (round to nearest Kcal) = 1,900 kcalsTDE= REE X AF X IF TDE= 1754 X 1.3 X 1 (no injuries)= 2,470TDE= 2,470 (round to nearest 50 kcal)= 2,500 Kcals per day 2500 kcals / 84.9 kg= 29.4 kcals/kg ii. DRIs for Boys Ages 14-18 yo (Table 1.9) Protein (g/kg/day) = 0.85 0.85 grams protein x 84.9 kg= 72.2 g PROiii. Fluids Requirements: Young Active (16-35 yo)= 35-40 ml/kg (35/40 ml x 84.9 kg)= 2,971.5 3396 ml

11. Nutrition related Medications Reviewed

MedicineFunctionPossible-Nutrition Related Side Effect

Novolog (insulin aspart) Fast-acting mealtime insulinHypoglycemia (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

12. Pertinent Labs Revieweda. Include labs available when assessing this patient:

LabNormal Reference Range(no diabetes)Target1/21/15

Hemoglobin A1c