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

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 inchesApnea-Hypoxia Index (AHI) – 59.3

(normal <1 in children, <5 in adults)REM AHI – 113.1Minimum O2 Sat – 68%

Past Medical History

ObesityDepression with suicidal ideation – history

of psych admit in 2005 for aggressionAsthmaSeasonal allergiesMultiple missed visits with sleep center

and weight management

Family History

AlbuterolMedications

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 CPAPMom reported M snoring and gasping

despite CPAPPt using Albuterol every day – started on

Flovent 110 and Singulair 10

Follow up NPSG8/25/10

Started on CPAP and titrated to +12cm H20Continued 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 hypertensionRecommended treatment – treat OSA

Adenotonsillectomy9/7/10

Tolerated procedure wellContinued 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

AnthropometricsWeight: 109 kg (240 #), > 97th %ileHeight: 151.6 cm, 50th %ileBMI: 47.5 kg/m^2, >97th %ileClassification: 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^2Mom 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 RecallAverage Daily Intake: 2356 kcal, 73 g fat57 % CHO, 28% fat, 15% proRDA for total kcal for a 12 YOF at the 50th

%ile is ~ 2000 kcal per dayDiet recall significant for lack of fruits and

non-starchy vegetables and large portionsM 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 DietGo foods:

Low in caloriesEat in unlimited amounts when prepared without fat

Yield foods:Contain more calories than “go” foodsMeals should contain 3-4 servings, snacks should

contain 2-3servings of “yield” foods. Correct portions contain ~120 calories

Stop foods:High in fat and sugarShould not be kept in the home, but enjoyed outside of

the homeGoal is to eat only 1 “stop” food per day or 7 per week

Stop Light Diet

Permanent, family changesAim 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 fitMom reports that kids like to dance

Family’s Positive Changes

Cut out sugary beveragesSwitched to low fat dairy productsMom reports that she has removed “stop”

foods from the homeSwitched to whole grain productsInitiated family exercise twice per weekMom seems to be highly motivated

Concerns

Continued weight gain despite family changesLack of portion controlBinging in the middle of the nightLikely decreased adherence to CPAP due to late

night eatingM has not received any formal Nutrition

InterventionRepeated 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 dayUse 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 snacksLocks for refrigerator and cabinets?

SOCIAL ASPECTS

Claire Lenker

Patient Timeline

DOB 2/24/98Meds/treatments:

Zoloft 25 mg once/day, began December 2010Flovent 110, 2 puffs, BIDSingulair, 10 mg, once per dayCPAP, + 12 cmwp

Specialty involvement: Sleep Disorders: Dr. MaddoxENT: Dr. ShirleyCBH: Dr. SrilataNARE Home Medical

Medical TimelineED visits age 1-2:

StrepSibling (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 schoolFamily hx of ADHD, antisocial behavior, LD, MR, Bipolar

d/o, schizophrenia, aggressionDx 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 girlM, 12 year old girlT, 11 year old girlD, 10 year old boyJ, 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 utilitiesS & J share a roomM & T share a roomChildren attend

Bessemer City Schools—never changed to “where they’re supposed to be”

Family ResourcesMom has a truck for

transportationThe truck is frequently

broken downJ’s dad takes all 5

children to school dailyMom worked for

Walmart X 10 years, increasingly difficult after child died and onset of depression, eventually terminated

? other support people—not specific

Medicaid for childrenPrimary 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

INM: SSI of $674/monthD: SSI of $674/monthFood Stamps

$463/monthMom’s unemployment

of $56/week recently stopped

No child support

OUTRent $217/month

(Section 8)Power Bill: between

$414 and $690 per month

No car paymentNo 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 IEPMom 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 gradeCurrently making D’s

and F’s in school“She’s a bully”

Pushes other studentsAggressive to teachers In danger of expulsion? Better on ZoloftNo 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!