Pediatric Type 1 Diabetes MINOR CASE STUDY BY: AMANDA HUNTER, DIETETIC INTERN.

Pediatric Type 1 DiabetesMINOR CASE STUDY

BY: AMANDA HUNTER, DIETETIC INTERN

Case Study Patient: BBADMITTING DX: DEPRESSION (SUICIDAL IDEATION)

HX: TYPE 1 DM (SINCE 2000), ADOLESCENT DEPRESSION, GAD (GENERAL ANXIETY DISORDER)

HEIGHT: 167CM WEIGHT: 73KG

AGE: 16YO SEX: FEMALE

Social History Parents: lives with father and step-mother

Biological mom has hx bipolar disorder

Siblings: 1 full sister, age 23. 1 half sister, age 6

Religion: Christian

Ethnicity: White/Caucasion

Education: 10th grade. Usually A, B student, but grades recently fell to C’s.

Marital Status: Single, recent break up with boyfriend of 2 months

Extracurricular Activities: No current. Past cheerleading

Hobbies: photography, pottery, cheerleading

Case study patient: BBOBJECTIVE:• WHY CHOSEN?

• FOCUS OF STUDY: ADOLESCENT DIABETES TYPE 1 IN A PATIENT WITH DEPRESSION

Pathophysiology of Type 1 Diabetes• CHRONIC ILLNESS / AUTOIMMUNE DISEASE THAT

ATTACKS PANCREATIC BETA CELLS

• PROGRESSIVE LOSS OF INSULIN PRODUCTION RESULTS IN HYPERGLYCEMIA

• CHILDREN AND ADOLESCENCE NEED EXOGENOUS INSULIN TO SURVIVE

• TYPE 1 DM IS 5-10% CASES

• GLOBAL INCREASE OF INCIDENCE PAST 30 YEARS

Disease Process: Type 1 DM• RAPID ONSET W/ FOLLOWING CLINICAL

SYMPTOMS:• Substantial weight loss

• Polyuria

• Polydipsia

• Hyperglycemia

• Ketoacidosis

Diagnosis of Type 1 Diabetes

DIAGNOSIS CRITERIA: (AMERICAN DIABETES ASSOCIATION, 2011)

•

A1C >/= 6.5%

• FPG (FASTING PLASMA GLUCOSE) >/= 126 MG/DL (7MMOL/L).  THIS TEST IS DONE AFTER NO INTAKE FOR AT LEAST 8 HOURS

• SYMPTOMS OF HYPERGLYCEMIA (POLYURIA, POLYDIPSIA, AND UNEXPLAINED WEIGHT LOSS) AND A RANDOM GLUCOSE OF >200MG/DL

• OGTT (ORAL GLUCOSE TOLERANCE TEST). 2 HR PLASMA GLUCOSE = 200MG/DL

This test uses a glucose load of 75 grams anhydrous glucose dissolved in water, or 1.75g / kg body weight if weight is less than 40 pounds. (C)

Past medical history of BB

DM TYPE 1 DIAGNOSED IN 2000

ADOLESCENT DEPRESSION PAST 3-4 YEARS WITH MULTIPLE PREVIOUS PSYCHIATRIC HOSPITALIZATIONS

H/O CUTTING BEHAVIOR

COMPLETED OUTPATIENT PROGRAMS FOR DEPRESSION

Christ outpatient psych program in Summer 2013

St. Joseph in Joliet in 2012

Present Medical Status of BB

• PATIENT’S SYMPTOMS UPON ADMISSION:1. Suicidal Ideation

2. Abnormal serum glucose

3. Uncontrolled diabetes

Disease condition: Adolescent Depression w/ Type 1 DM • ADOLESCENTS W/ TYPE 1 DM 2X MORE LIKELY

TO HAVE DEPRESSION

• STUDY FOUND DEPRESSIVE SYMPTOMS INDIRECTLY RELATED TO A1C LEVEL

• TREAT DEPRESSION WITH MEDICATIONS AND/OR THERAPY

Treatment Plan for BB:

TREATMENT GOALS FOR AGE 13-19:

• BLOOD GLUCOSE BEFORE MEALS:  90-130MG/DL

• BEDTIME/OVERNIGHT BLOOD GLUCOSE:  90-150MG/DL

• A1C < 7.5%

• GLYCEMIC GOALS SHOULD BE INDIVIDUALIZED.  A LOWER GOAL CAN BE ACHIEVED AS LONG AS THERE IS NO INCREASED RISK OF HYPOGLYCEMIA.

• IF THERE IS A DIFFERENCE BETWEEN PREPRANDIAL GLUCOSE LEVELS AND A1C, POSTPRANDIAL GLUCOSE SHOULD BE MEASURED TO DETERMINE THE APPROPRIATE AMOUNT OF BASAL/BOLUS INSULIN.

• CHILDREN WHO EXPERIENCE FREQUENT HYPOGLYCEMIA SHOULD HAVE A HIGHER GLYCEMIC GOAL. (C )

Patient’s Diagnosis and Lab FindingsDX: ADOLESCENT DEPRESSION, TYPE 1 DIABETES MELLITUS

Lab 1/06/2015 High / Low

Possible Indications

Glycemic Control

Blood glucose

Alb 4.4 WNL n/a 1/6 240, 191, 264, 331

TP 7.2 WNL n/a 1/7 288, 274, 219, 290

HbA1c 9.5% High Uncontrolled Diabetes

1/8 193, 272, 303, 189

Est ave gluc

226 High Uncontrolled Diabetes

1/9 241, 272, 317, 179

UA glucose 4+ High Diabetes 1/10 189, 287, 191, 287

UA ketones 1+ High Uncontrolled diabetes, fasting

1/11 217, 194, 343, 271

UA protein Trace   Diabetes 1/12 261, 246, 241, 272

        1/13 215, 184

MedicationsMedication Dosage Use Interactions

Prozac (Prior to admit)

10mg /day SSRI antidepressant

Alcohol, no food interactions

Escitalopram (Lexapro)

10mg @ bedtime

SSRI antidepressant, anxiety

Alcohol, no food interactions

Insulin detemir (Levemir)

30 units subQ @ bedtime

Long lasting insulin for Insulin-dependent diabetes

Alcohol, no food interactions.Gatafloxacin

Insulin lispro (HumaLOG)

subQ w/ meals Fast acting insulin for Insulin dependent diabetes

Alcohol, no food interactions.Gatafloxacin

Medical Nutrition Therapy NUTRITION HISTORY:

HOME DIET: REGULAR

SPECIAL CONSIDERATIONS: PATIENT STATES SHE WILL EAT LESS SUGARY FOODS – SODA, CANDY, ICE-CREAM – WHEN BLOOD GLUCOSE READINGS ARE HIGHER (> 200MG/DL)

DIET PATTERN: 3 MEALS, 2 SNACKS

Analysis of diet (24 hr recall)BB’s Diet Hisotry

5:45am – Wake up    6:00am – Breakfast

 Goal: 3-4 carbs

2 eggs2 sausage links

1 slice toast2 cups milk, 1%

3 carbs4 protein

2 fats

11:30am – Lunch 

Goal: 4-5 carbs 

1 ½ cups salad2 TB ranch dressing

1 cup grapes1 granola bar

1 can diet coke

2 ½ carbs0 protein

2 fats

2:30pm – Afternoon snack 

Goal: 1-2 carbs 

1 whole fruit or chips1 can diet coke

1-2 carb0 protein

0 fat

6:00pm – Dinner 

Goal: 4-5 carbs 

4oz chicken breast1 cup mashed potatoes

2 cups milk, 1%1 cup salad

2 TB ranch dressing

4 carbs4 protein

2 fat

9:00pm – PM snack 

Goal: 1-2 carbs 

1 banana 2 carbs 0 protein

0 fat

Medical Nutrition Therapy CURRENT PRESCRIBED DIET: THE CURRENT DIET IS DIABETIC 2000KCAL, CONTROLLED CARBOHYDRATE, NO CAFFEINE.

THIS DIET ORDER IS IN PLACE DUE TO THE PATIENT’S DIAGNOSIS OF UNCONTROLLED DIABETES. THE CALORIE ALLOWANCE IS BASED ON THE PATIENT’S ESTIMATED ENERGY NEEDS. THE CARBOHYDRATE EXCHANGES OF 5 CARBS FOR BREAKFAST, 6 CARBS FOR LUNCH AND 6 CARBS FOR DINNER ARE GUIDELINES FOR THE PATIENT’S MEALS TO HELP KEEP HER CARBOHYDRATE INTAKE CONSTANT IN ORDER TO STABILIZE HER BLOOD SUGAR. THE CAFFEINE RESTRICTION IS DUE TO HER INSOMNIA AND ANXIETY.

PATIENT’S RESPONSE TO THE DIET: COMPLIANT.

Medical Nutrition Therapy NUTRITION RELATED PROBLEMS: UNCONTROLLED DIABETES, OVERWEIGHT

PRESENT NUTRITIONAL STATUS: OVERWEIGHT, HYPERGLYCEMIA

EER: 2000KCAL / DAY

PROTEIN REQUIREMENTS: 15-20% =75-100G = 10-14OZ / DAY

FLUID REQUIREMENTS: 1620ML (1500ML + 20ML FOR EVERY INCH OVER 60INCHES)

Patient’s Nutrition Education Process• NUTRITION CONSULT FOR ABNORMAL SERUM GLUCOSE

AND UNCONTROLLED DIABETES.

• NUTRITION ASSESSMENT AND EDUCATED ON CARBOHYDRATE COUNTING AND MENU SELECTION.

• THE PATIENT AND THE PATIENT’S FATHER EXPRESSED NO NEED OR DESIRE FOR FURTHER DIABETIC EDUCATION.

• THE PATIENT WAS COOPERATIVE IN PROVIDING INFORMATION ON HER HISTORY OF DIABETES, MEDICATION, AND DIET RECALL.

• FEEDBACK WAS PROVIDED ON HER DIET RECALL

• STRESSED IMPORTANCE OF FOLLOWING A CONSTANT CARBOHYDRATE DIET IN ORDER TO MANAGE BLOOD SUGAR WAS STRESSED.

Prognosis• MANAGEMENT OF DEPRESSION, THE PATIENT’S

PROGNOSIS IS GOOD

• follows medication regimen and continues to see her therapist

• MANAGEMENT OF DIABETES, PT’S PROGNOSIS IS FAIR TO GOOD

• The success of using insulin therapy to manage diabetes is dependent on her knowledge, self-management skills, and support system. E

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15, 2015, FROM HTTP://WWW.NUTRITIONCAREMANUAL.ORG/TOPIC.CFM?NCM_CATEGORY_ID=13&LV1=144621&LV2=144762&NCM_TOC_ID=144762&NCM_HEADING=NUTRITION CARE

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4. MCGRADY, M. E., & HOOD, K. K. (2010). DEPRESSIVE SYMPTOMS IN ADOLESCENTS WITH TYPE 1 DIABETES: ASSOCIATIONS WITH LONGITUDINAL OUTCOMES. DIABETES RESEARCH AND CLINICAL PRACTICE, 88(3), E35–E37. DOI:10.1016/J.DIABRES.2010.03.025

5. HOOD, K. K., RAUSCH, J. R. AND DOLAN, L. M. (2011), DEPRESSIVE SYMPTOMS PREDICT CHANGE IN GLYCEMIC CONTROL IN ADOLESCENTS WITH TYPE 1 DIABETES: RATES, MAGNITUDE, AND MODERATORS OF CHANGE. PEDIATRIC DIABETES, 12: 718–723.