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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.

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Interdisciplinary Case Study: A 12 year old with OSA

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  1. Interdisciplinary Case Study:A 12 year old with OSA Mary Halsey Maddox, Sleep Fellow Julianna Bailey, Nutrition Trainee Claire Lenker, PPC Social Worker

  2. MEDICAL ASPECTS Mary Halsey Maddox

  3. Initial Contact7/20/10 • 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%

  4. 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

  5. Family History Medications Albuterol Obesity Sleep Apnea Learning Disorders Bipolar Disorder Schizophrenia Diabetes

  6. 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

  7. Clinic Visit8/24/10 • Reinforced importance of CPAP • Mom reported M snoring and gasping despite CPAP • Pt using Albuterol every day – started on Flovent 110 and Singulair 10

  8. Follow up NPSG8/25/10 • 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 non-compliance)

  9. Cardiology Evaluation9/2/10 • Mild secondary pulmonary hypertension • Recommended treatment – treat OSA Adenotonsillectomy9/7/10 • Tolerated procedure well • Continued CPAP +12cm H2O

  10. Follow Up NPSG11/10/10 • 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

  11. NUTRITIONAL ASPECTS Julianna Bailey

  12. 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.

  13. 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.

  14. 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.

  15. 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

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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?

  21. SOCIAL ASPECTS Claire Lenker

  22. 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

  23. 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

  24. 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.

  25. 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 40-45. 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

  26. 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”

  27. 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

  28. 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”

  29. 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……….

  30. 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.

  31. 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 extra-curricular 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

  32. 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.

  33. 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

  34. 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

  35. Medical Questions and alternative strategies?

  36. Nutrition Questions and alternative strategies?

  37. Social Questions and alternatives?

  38. 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!

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