Pediatric Nutrition Internship

Intern: 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 admission
a. 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%

2.
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9.

a. Justify nutritional significance: Ptknowntoskipmealsfrequently,whichtends

toleadtoextremehungerandexcessiveintakeofcarbohydraterichfoodsat
nighttime,increasinghisriskforhyperglycemia.Asaresultofptspoor
glycemiccontrol,heconsistentlyhashighbloodsugarlevelsandanelevated
hemoglobinA1c(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.
Diet Order: Carbohydrate Controlled Diet + CHO counting
a. On Classic Basal Bolus Therapy: getting Lantus at a dose of 55 units at bedtime
b. Carb ratio is 1:5 with a correction factor of 25.
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
Weight: 84.9 kg (187.2 lb)
a. Percentile: 95th %ile
b. Corrected weight percentile: n/a
c. Weight age: 61.9 kg (50th %ile)
Height: 180 cm (70.9 in)
a. Percentile: 79 %ile
b. Corrected height percentile: n/a
c. Height age: 174 cm (50th %ile)
Head Circumference: n/a- the WHOheadcircumferenceforagechartsandtablesare
frombirthto5yearsofage.Measurementistypicallytakenwithchildrenages03years
old.
a. Percentile: n/a
b. Corrected head circumference percentile: n/a
c. Head circumference age: n/a
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
Body Mass Index/percentile: 26.2 kg/m2 / 92%ile
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 him at the 91st
percentile for boys ages 16 years. This means JC is overweight. According to
the CDC BMI-for-age growth chart, overweight is any 85th to less than the
95th percentile. A healthy weight for JC would be between the 5th percentile and
up to the 85th percentile.
10. Estimated Requirements
a. Energy Needs: Kcals/kg: 29.4 kcals/kg
b. Protein Needs: Grams Protein/kg: 0.85 grams protein/kg
c. Maintenance fluid needs mL/day: 2,971.5 3396 ml
d. Justify how you determined these numbers
i.
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 kcals
REE= 1899.5 (round to nearest Kcal) = 1,900 kcals
TDE= REE X AF X IF

ii.
iii.

TDE= 1754 X 1.3 X 1 (no injuries)= 2,470

TDE= 2,470 (round to nearest 50 kcal)= 2,500 Kcals per day
2500 kcals / 84.9 kg= 29.4 kcals/kg
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 PRO
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

Medicine

Function

Novolog (insulin
aspart)

Fast-acting mealtime insulin

Lantus (insulin
glargine)

Long-acting basal insulin

Lisinopril

ACE inhibitor

Levothyroxine

Thyroid hormone replacement

Lamictal

Anticonvulsant/ mood stabilizer

Possible-Nutrition Related
Side Effect
Hypoglycemia (excessive
hunger, nausea), hyperglycemia
(increased thirst, weight loss),
hypokalemia (dry mouth,
increased thirst)
Hypoglycemia, hyperglycemia,
hypokalemia
Abdominal pain, diarrhea,
nausea, vomiting, sore throat,
loss of appetite
Difficulty with swallowing,
nausea, swelling of lips, throat,
or tongue, diarrhea,
Bloody stools, painful mouth
sores, sore throat, trouble
breathing, loss of appetite, or
weight loss, dry mouth

12. Pertinent Labs Reviewed

a. Include labs available when assessing this patient:
Lab

Hemoglobin A1c
14-day average blood

Normal Reference Range

(no diabetes)

Target

1/21/15

<5.7%

<7%

13.8%

Less than 140 mg/dL

150

Breakfast 303, lunch 397,

sugars

(7.8 mmol/L)

BloodPressure

Lessthan120/80mmHg

dinner 287, bedtime 310

<120/80

125/75mmHg

b. Note labs deemed to be nutritionally significant and justify why

Hemoglobin A1c (glycated hemoglobin): is used to identify the average

plasma glucose concentration over the past 2-3 months. When diabetes is
not controlled, sugar builds up in the blood and combines with
hemoglobin, becoming glycated. A high HbA1c is associated with
rapid progression of diabetic microvascular complications. However,
although JCs glucose control has been consistently poor, his Alc is
slightly better than his previous visit with Endocrinology on 11/7/2014
with a HbA1c of over 14%.

14-day average blood sugars: High blood sugar levels over long periods
of time can lead to serious complications such as heart disease, blindness,
kidney failure, and amputation. Very high blood sugar levels can lead to
diabetic ketoacidosis (DKA), or a diabetic coma. JCs high blood
glucose levels are a result of his poor diabetes management, including
skipping his insulin dosages, skipping meals and then eating large
quantities later in the day, and consuming food with higher glucose
content without injecting extra insulin.

High Blood Pressure (hypertension): In type 1 diabetes, high blood

pressure (hypertension) usually develops if the kidneys are damaged. JC
has suboptimal glycemic control with a history of proteinuria on a
random urine specimen in Nephrology Clinic. This was thought to be
secondary to renal injury (glomerular hyperfilteration), consistent with
diabetic nephropathy. Of the environmental factors that affect BP (diet,
physical inactivity, toxins, and psychosocial factors), dietary factors have
a likely predominant, role in BP homeostasis. Sodium (salt) intake should
be limited to 1,500 mg/day or less. Reducing sodium can help lower
blood pressure and decrease the risk of heart disease.

Assessment:
1. Nutrition risk level: Overweight/ uncontrolled type 1 diabetes/ binge eating disorder
a. Justify choice of risk level: Pt BMI-for-age is in the 91st %ile. Pt has
uncontrolled type 1 diabetes given his difficulty with consistent blood sugar
checks, missed insulin injections and skipped meals over the past year. Pt
reported excessive food intake and grazing late at night, usually on large
amounts of sugary or carbohydrate-rich foods. These irregular patterns of eating
have greatly contributed to JCs blood sugars levels, elevated blood pressure, and
weight status.

2. Pertinent Lab values: Please see above

a. Justify their relationship to nutrition/hydration status: please see above
3. IV fluids: n/a- JC is not receiving IV fluids
a. Justify their relationship to nutrition/hydration status: n/a
4. Growth
a. Rate of weight change:
DateofMeasurement

Weight

January29,2014
February14,2014
April16,2014
May20,2014
July23,2014
November22,2014
November26,2014
January21,2015

86.8kg
85.5kg
88.3kg
87.0kg
83.9kg
84.0kg
86.3kg
84.9kg

Rateofweight
change

1.3kg
+2.8kg
1.3kg
3.1kg
+0.1
+2.3kg
1.3kg

b. Appropriateness of growth: JCs weight has fluctuated over the past year
between 83.9 kg and 88.3 kg. These changes in weight are likely due to his
irregular eating patterns and history of excessive food intake. For JCs age he is
overweight.
c. Justify your assessment: JC is overweight because his BMI-for-age (26.2
kg/m2) on the CDC growth chart places him at the 91st percentile for boys ages
16 years of age. JC admits to frequent binges late at night and poor dietary
compliance to a carbohydrate restricted diet. This can lead to weight gain and
cause high blood sugar levels.
5. Diet prior to admission
a. Adequacy of macro and micronutrients: Pt has poor glycemic control, likely
not reaching macro and micronutrient needs. JC often skips meals, leading to
excessive hunger later in the day. JC usually would overconsumemicronutrient
poorprocessedfoods(i.e.:pasta,sugar,andsoda), with minimal intake of fruits
and vegetables. It is likely JC was lacking in both macro and micronutrients
secondary to his poor dietary choices.
b. Adequacy of fluid: n/a- pt did not report about his fluid intake
c. Appropriateness of supplements: n/a- pt does not take any supplements
d. Contribution of supplements to overall intake: n/a
e. Justify your assessment: Pt has a history excessive food intake, grazing late at
night, skipping meals and lack of carbohydrate control. A poor diet is generally
associated with both macro and micro deficiencies. In addition, people with
eating disorders and diabetes often use unhealthy strategies to control their
weight, which sometimes leads to weight gain.
6. Diet order

a. Adequacy of macro and micronutrients: Given JCs history of psychological

disorders, we did not collect a dietary recall but rather encouraged a general
healthy dietary pattern, including eating regularly (3 meals a day) and
incorporating more vegetables in the diet. In addition, we encouraged JC to
always eat breakfast and avoid late night binges by snacking on vegetables,
which may help to improve his blood sugar levels.
b. Adequacy of fluid: n/a- pt did not report about fluid intake
c. Appropriateness of supplements: n/a- pt does not take any supplements
d. Contribution of supplements to overall intake: n/a
e. Appropriateness of administration: n/a
f. Justify your assessment: Pt ordered for carbohydrate controlled (counting is
carbohydrates at meal) with carb ration 1:5 and a correction factor of 25. If JC
was to count his carbohydrates at every meal, take the appropriate amount of
insulin prescribed and avoid skipping meals, he could reach his macro and
micronutrient needs and hopefully improve his glucose control.
7. Accuracy of data available: The accuracy of the data above is based off the
information from JCs visits with Nephrology, Endocrinology, and Nutrition.
Information provided through patient and mother seems accurate.
Plan/Goals:
1. Oral nutrition:
Continue carbohydrate counting
Recommend a normal eating schedule
i. Pack a breakfast for on-the-go/pack lunch at night
ii. Setting an alarm to take Levothyroxine
Limit consumption of sugary and carbohydrate-rich foods, especially late at
night
iii. Snacking on vegetables during the evening
Monitor blood sugar checks (4x/day) and insulin injections
Reasonable weight loss goal
iv. 50-84%ile = 61.9kg (134lb)- 74.3kg (164lb) or
v. 75-84%ile given ED history = 70 (154lb)- 74.3kg (164lb)
2. Enteral nutrition: n/a- JC does not receive Enteral nutrition
3. Parenteral nutrition: n/a- JC does not receive Parental nutrition
4. Labs/Studies: Hemoglobin A1c and blood sugars should continue to be monitored.
5. Growth: Overweight (BMI-for-age: 91st percentile)
6. Additional information needed: A 24-hour dietary recall or food journal to determine
exactly what JC is eating on a day-to-day basis.
7. Follow up: JC will return back in 3 months time.
8. Justify your plan/goals:
a.
Use phone and mom as reminders for dinnertime insulin shots
b.
Check blood sugar at breakfast, lunch, dinner and nighttime
c.
Eat all 3 meals daily
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.

Evaluating Intern Written Case Study

1

Organization &
Structure

Does not use CNMC

case study format.

Unclear use of CNMC

case study format

Some use of CNMC

case study format

Uses CNMC case

study format.

Scholarly Journal
Article

No scholarly journal
article used as
reference.

Scholarly journal
article used as
reference but is not
relevant to topic.

Scholarly journal
article used as
reference and is
relevant to topic.

Development of
Ideas & Use
Supportive
Evidence

Fails to develop
information beyond
the minimum
requested. Completely
lacks relevant and
accurate supporting
information/
examples/ discussion.

Minimal supporting
information/
examples/ discussion
and/or are irrelevant
or inaccurate.

Scholarly journal
article used as
reference but is only
minimally relevant to
topic.
Provides relevant
information/
examples/ discussion
that adequately
explains or develops
understanding of the
assignment, but more
is needed or some is
inaccurate.

Growth Chart

No growth chart used

for the assignment

Growth chart used for

the assignment but is
inappropriate for case
study or plotting is
inaccurate.

Growth chart used for

the assignment is
appropriate for case
study but plotting is
inaccurate.

Assessment Form

No assessment form
used for the
assignment.

Assessment form is
used, but information
presented is largely
inaccurate or lacks
sufficient elaboration
to be used in a clinical
setting.

Information presented
is largely accurate and
could be used in a
clinical setting with
minimal
modifications.

Provides accurate,
relevant,
purposeful
information/
examples/
discussion that
develop and/or
expand on the
assignment
effectively.
Growth chart used
for the assignment
is appropriate for
case study and
plotting is
accurate.
Information
presented is
accurate and could
be used in a
clinical setting
without
modifications.

Comments

Preceptor Signature: ________________________________

Reviewed/Revised 12/2011ck

Date: ___________________