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 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%
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
Family History Medications Albuterol 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 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
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)
Cardiology Evaluation9/2/10 • Mild secondary pulmonary hypertension • Recommended treatment – treat OSA Adenotonsillectomy9/7/10 • Tolerated procedure well • Continued CPAP +12cm H2O
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
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 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
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 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
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
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!