Interdisciplinary Case Study: A 12 year old with OSA
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Transcript Interdisciplinary Case Study: A 12 year old with OSA
Interdisciplinary Case Study:
A 12 year old with OSA
Mary Halsey Maddox, Sleep Fellow
Julianna Bailey, Nutrition Trainee
Claire Lenker, PPC Social Worker
MEDICAL ASPECTS
Mary Halsey Maddox
Initial Contact
7/20/10
11yoF for nocturnal polysomnogram –
referred for snoring, poor quality sleep,
and enuresis
Weight 225 pounds, Height 59 inches
Apnea-Hypoxia Index (AHI) – 59.3 (normal
<1 in children, <5 in adults)
REM AHI – 113.1
Minimum O2 Sat – 68%
Past Medical History
Obesity
Depression with suicidal ideation – history
of psych admit in 2005 for aggression
Asthma
Seasonal allergies
Multiple missed visits with sleep center
and weight management
Medications
Albuterol
Family History
Obesity
Sleep Apnea
Learning Disorders
Bipolar Disorder
Schizophrenia
Diabetes
Initial Intervention
Reviewed record, called PMD, and
realized multiple missed visits with sleep
lab and weight management
Informed family patient had life-threatening
apnea and that lack of compliance with
medical recommendations by family would
result in immediate DHR involvement
Started patient on CPAP autotitration +4+12cm H2O
Clinic Visit
8/24/10
Reinforced importance of CPAP
Mom reported M snoring and gasping
despite CPAP
Pt using Albuterol every day – started on
Flovent 110 and Singulair 10
Follow up NPSG
8/25/10
Started on CPAP and titrated to +12cm H20
Continued to have apneic events and was
changed to BIPAP and titrated to 13/6 with
complete resolution of events
Overall had AHI of 14.9 with lowest O2 sat
73% - significant improvement
Did not change to BIPAP because did not
follow up in clinic before ENT appointment
(probably timing, not necessarily noncompliance)
Cardiology Evaluation
9/2/10
Mild secondary pulmonary hypertension
Recommended treatment – treat OSA
Adenotonsillectomy
9/7/10
Tolerated procedure well
Continued CPAP +12cm H2O
Follow Up NPSG
11/10/10
Weight – 241.4 pounds, Height – 60.4
inches
AHI off CPAP 6.8, REM AHI 20.4, Lowest
O2 saturation 86% (91% on CPAP)
CPAP titrated to +5cm H2O with resolution
of events
Significant improvement but still with
significant sleep apnea
Plan for follow up in early 2011
NUTRITIONAL ASPECTS
Julianna Bailey
Nutrition History
Anthropometrics
Weight: 109 kg (240 #), > 97th %ile
Height: 151.6 cm, 50th %ile
BMI: 47.5 kg/m^2, >97th %ile
Classification: Obese
Weight for a 12 YOF at the 50th%ile is ~ 92 #
BMI for a 12 YOF at the 50th %ile is ~ 18 kg/m^2
Mom states that M has gained ~35 #s in the past
year.
M has received no formal nutrition intervention
although 3 of her siblings attend WM clinic.
24 Hour Recall
Average Daily Intake: 2356 kcal, 73 g fat
57 % CHO, 28% fat, 15% pro
RDA for total kcal for a 12 YOF at the 50th
%ile is ~ 2000 kcal per day
Diet recall significant for lack of fruits and
non-starchy vegetables and large portions
M reportedly eats “anything she can get”
late at night while the rest of the family
sleeps.
M’s diet recall does not include late night
eating.
Intake
M and her siblings usually eat breakfast
and lunch at school on weekdays.
Mom reports that they follow the stop light
diet at home.
Stop light diet provides roughly 1500-2280
kcal daily.
M lost 7 # when family initiated lifestyle
changes
M Gained weight back when she started
eating late at night.
Stop Light Diet
Go foods:
Low in calories
Eat in unlimited amounts when prepared without fat
Yield foods:
Contain more calories than “go” foods
Meals should contain 3-4 servings, snacks should
contain 2-3servings of “yield” foods.
Correct portions contain ~120 calories
Stop foods:
High in fat and sugar
Should not be kept in the home, but enjoyed outside of
the home
Goal is to eat only 1 “stop” food per day or 7 per week
Stop Light Diet
Permanent, family changes
Aim for 3 meals and 2-3 snacks per day.
Meals and snacks should be made of “yield”
foods with “go” foods added.
After eating a meal, wait 30 minutes before
getting seconds.
Do not eat food straight out of the package or in
the bedroom. Use correct portion sizes.
Physical activity goal is 5 X per week for 30-45
minutes each time.
Physical Activity
M is in a PE class at school that lasts for ~
1 hour each weekday.
Family takes short walks twice per week.
Mom just bought a Wii fit
Mom reports that kids like to dance
Family’s Positive Changes
Cut out sugary beverages
Switched to low fat dairy products
Mom reports that she has removed “stop”
foods from the home
Switched to whole grain products
Initiated family exercise twice per week
Mom seems to be highly motivated
Concerns
Continued weight gain despite family changes
Lack of portion control
Binging in the middle of the night
Likely decreased adherence to CPAP due to late
night eating
M has not received any formal Nutrition
Intervention
Repeated no-show to WM appointments, did not
re-schedule
Nutrition Plan
Praised Mom for positive, family-centered
changes
Goals:
Increase fruits and non starchy vegetables to at least 3
servings per day
Use correct portions of “yield” foods
Increase Family physical activity to 5 X per week.
Re-schedule M’s WM orientation appt
Attempt to get all 5 children into WM “siblings”
clinic on Thurs mornings
Keep “go” foods readily available for snacks
Locks for refrigerator and cabinets?
SOCIAL ASPECTS
Claire Lenker
Patient Timeline
DOB 2/24/98
Meds/treatments:
Zoloft 25 mg once/day, began December 2010
Flovent 110, 2 puffs, BID
Singulair, 10 mg, once per day
CPAP, + 12 cmwp
Specialty involvement:
Sleep Disorders: Dr. Maddox
ENT: Dr. Shirley
CBH: Dr. Srilata
NARE Home Medical
Medical Timeline
ED visits age 1-2:
Strep
Sibling (age 7) died 10/2004: playing in pool, “choked
on pizza” and drowned; sibling and M (age 6) were
very close
Psych Admission 4/2005—aggressive at home and
school
Family hx of ADHD, antisocial behavior, LD, MR, Bipolar
d/o, schizophrenia, aggression
Dx of PTSD & ODD
IQ 84
DC plan: weekly therapy at CBH, meds (Metadate CD 10mg) to
be managed by Western MH, referral to JBS for in-home
therpay, close supervision to prevent dangerous behaviors,
“address violence in the home that M is exposed to”, and
intensive behavior therapy
Psych follow up +/- during 2005 – 2006 at CBH and
Western MH; stopped Metadate at some point.
Unclear history of being on Claritin, Albuterol/Ventolin
Medical Timeline, slide #2
After hours visit 11/06: strep
PMP vs 7/20/09:
CC of strong urine odor; primary
enuresis, moody, withdrawn, mom
hiding knives, wt gain of 23# in 6
months, needs check up
PMP vs 7/23/09:
wt. 205, ht 58”
Obesity, primary enuresis,
snoring, possible OSA, foot pain,
acanthosis on exam; restart
Miralax
Referrals for Urology and SS
Sleep Study 10/21/09: no show
Urology 11/23/09: no show
Weight Mgmt Orientation 1/8/10:
no show
ED 2/17/10: sore throat, wt 95kg
PMP 6/18/10:
Threatening other family members
with knives, missed JBS follow up,
?Medicaid issue?; 20# wt gain (wt
225#, ht 59”); enuresis somewhat
better; still snoring, did not keep
urology or SS appts. Mom to
reschedule JBS and weight mgmt
appts; Hemoglobin A1C = 6.4,
cholesterol, triglycerides wnl
SS 7/20/10:
AHI 45.4, ↓REM, apnea index 59.3,
113/hour in REM sleep, ETCO2 high of
54, refer to ENT and f/u in CPAP clinic
7/29/10: Set up on CPAP “+4 +12”
ENT 8/17/10: Schedule for T&A,
to ED for suicidal thoughts
ED 8/17/10: on no meds, wt 106.5
kg, to see psych as outpt.
Medical Timeline, slide #3
CBH 8/19/10
CPAP clinic 8/24/10:
PFTs, FVC 113%, FEV1 108%;
unable to download compliance
card; tired; falls asleep at school;
using Ventolin daily; Mallampati II;
tonsils 3+. Start Flovent and
Singulair, get titration study
SS: 8/25/10:
index of 30.4 on +4, up to 12,
better on BiPAP of 13/6 with
complete resolution of OSA; 108
respiratory events, AHI 14.9,
desats on CPAP to 73%, lowest
on BiPAP was 93%; ETCO2 4045. Plan to try CPAP of +12 for
now
Cardiology 9/2/10:
wt 108kg, mild secondary
pulmonary HTN, OSA, obesity,
RTC 1 year
Inpatient 9/7-9/8/10: T & A
Weight Mgmt Orientation 9/24/10:
no show/cancelled?
Sleep Study 11/10/10:
AHI 6.8 off CPAP, events resolved
at +5, REM AHI 20.4, lowest O2 sat
91-92% on CPAP, 86% off CPAP,
stay on +5 for now
CBH 12/1/10, 1/19/10
Upcoming appts:
CPAP Clinic: due 1/25/11
CBH: due 4/19/11
Does not currently have
weight management
scheduled
Psychosocial History
Family Composition
Mom
5 living children:
S, 15 year old girl
M, 12 year old girl
T, 11 year old girl
D, 10 year old boy
J, 6 year old girl
Sibling died in 2004 at
age 7 -- drowning and
aspiration
M and T are full siblings
J’s dad very involved but
does not live in the home
Living arrangements:
Live in 4 BR house in
Jones Valley (Bham
city, near boundary
w/Midfield)
All electric utilities
S & J share a room
M & T share a room
Children attend
Bessemer City
Schools—never
changed to “where
they’re supposed to be”
Family Resources
Mom has a truck for
transportation
The truck is frequently
broken down
J’s dad takes all 5
children to school daily
Mom worked for
Walmart X 10 years,
increasingly difficult
after child died and
onset of depression,
eventually terminated
? other support
people—not specific
Medicaid for children
Primary Care: Dr. Joni
Gill at Public Health
Dept.
ADPH SW now helping
mom with Medicaid
NETS reimbursement
Mom keeps a folder
with appointments and
other information
Finances
IN
M: SSI of $674/month
D: SSI of $674/month
Food Stamps
$463/month
Mom’s unemployment
of $56/week recently
stopped
No child support
OUT
Rent $217/month
(Section 8)
Power Bill: between
$414 and $690 per
month
No car payment
No other recurring
expenses
“We manage”
Family Health Issues
Mom describes herself
and all 5 children as very
overweight
Mom has hypertension
and diabetes, takes
Metformin and a BP med
Mom has no insurance,
Metformin is on $4 Wal
Mart program
BP med is ~ $65 per
month
Mom reports Depression
and Anxiety since 2004
Mom states all 5 children
should be attending
weight management clinic
D has ADHD and severe
stuttering problem
And the other
siblings……….
Siblings’ Health Issues
T – medical record: DOB 11/5/99
No show to Wt Mgmt 1/8/10
enuresis and encopresis noted in
history
SS 7/20/10: BMI 43.8, AHI 42, to
ENT, f/u in CPAP clinic
Adenoidectomy 9/7/10
Wt Mgmt appt. 9/24/10 cx
Urology 10/19/10: urgency, h/o
UTI, day and night wetting; RTC in
a month for KUB and renal US,
refer to GI
SS 11/10/10: AHI 22.3 with no
CPAP; titrated to +9, f/u in CPAP
clinic and put on CPAP at that
time
ENT post op appt 11/29/10: doing
better on CPAP, needs Wt Mgmt
appt.
No show to Urology f/u 11/30/10
No show to GI 12/15/10
Currently has NO scheduled
appointments
J – medical records: DOB 8/24/04
PMP vs 3/12/09: does not mind
mom, wt 71.2#, urinary frequency,
constipation; put on MIralax
PMP visit 7/23/09: states she will
kill everyone, recent episode with
knife; urinary accidents; ; wt
78.8#; ht 45.5”; acanthosis, WM
referral
No show to Wt Mgmt 1/8/10
SS 7/20/10: AHI 4.8, 15 during
REM; refer to ENT
7/29/10: Wt Mgmt appt, saw RD;
coordinate f/u w/sibling appts.
T & A 9/7/10
Urology 10/19/10: urgency, day
and night wetting; RTC in a month
for KUB and renal US, refer to GI
No show to Urology f/u 11/30/10
No show to GI 12/15/10
ENT post op appt. 1/10/11 (storm)
Appt. with Dr. Lozano 1/20/11,
New Sleep Pt.
School/Community
Family attends local
Baptist church across
the street intermittently
D has a 1:1 aid at
school and has an IEP
Mom sees contrast
between this and M’s
situation
Mom states M has no
friends, does not
participate in any extracurricular activities
M is in 7th grade
Currently making D’s
and F’s in school
“She’s a bully”
Pushes other students
Aggressive to teachers
In danger of expulsion
? Better on Zoloft
No IEP or supports but
Mom has requested
these, school wants to
see how she does on
Zoloft
Strengths/Concerns
Mom appears motivated
however chronic no
shows for multiple
children with multiple
specialties
Good relationship with
PMP
SW at ADPH helping with
Medicaid NETS
Live close to specialty
care
Dad helps with school
transportation
No significant financial
instability
Mom states enuresis is
better for both M and T
since starting CPAP
Safety issues
M and J both with history of
making threats, handling knives
Mom found M up in the night
boiling eggs, filled house with
smoke
School
Out of zone right now
M is failing
Threat of expulsion due to
behavior
No real plan for supports at
school
No care coordination for M, T, &
J
J has been to WM clinic but not
the M or J
T is on CPAP but does not have a
f/u appt scheduled
M has CPAP appt 1/25/11 and J
has New Sleep appt 1/20/11.
SW Recommendations
School intervention for
M
Consider family
appointments for both
Weight Management
Clinic and Sleep/CPAP
clinic
Closer monitoring of
keeping follow up visits
So why “M” and the entire “B” family?
M is the type of teenage sleep apnea
patient on the rise, though an extreme
M’s sleep apnea and problems are not
isolated to her – her entire family has
sleep apnea and obesity
It’s certain that her medical, social, and
nutritional issues are linked
Medical Questions and alternative
strategies?
Nutrition Questions and alternative
strategies?
Social Questions and alternatives?
Interdisciplinary take home points…
It takes a village to raise a child and often a
village to heal a child and/or family
Respect your team – sometimes the person
with the least amount of training makes
the biggest impact
Play nice!