a. Feeding History: DB has restricted intake and voluntary emesis. b. Method of feeding: DB feeds himself using a fork and knife.

Transcription

1 Subjective: PES 1. DB is a 14 year old previously healthy white male admitted to Children s National Medical Center (CNMC) with consistent weight loss, and malnutrition. His past medical history is consistent with restrictive intake, intentional weight loss and purging behavior for about 1 year. DB appears malnourished and thin. 2. Diet history prior to admission: DB became a vegetarian one year ago (mid 2010) after his older sister transitioned to a vegetarian diet. DB restricts calories at meals, although per the patient s parents, he eats all of his meal at breakfast, lunch, and dinner in their presence. DB stated that he eats very little food and admitted to purging a couple times per week. However, his parents reported that DB purges food daily and that is the reason why he is not gaining weight. a. Feeding History: DB has restricted intake and voluntary emesis. b. Method of feeding: DB feeds himself using a fork and knife. c. Oral/Enteral Intake: Breakfast cereal and milk, toast with no butter; Lunch peanut butter and jelly sandwich (usually eats only half), fruit, and chips or pizza; Dinner vegetables and meat alternatives such as veggie burgers. d. DB does not take any vitamin or mineral supplements. e. Food Allergies: None 1. Inadequate oral intake (NI-2.1) related to disordered eating and weight loss as evidenced by patient restricting intake and purging after meals and BMI <3 rd percentile. a. The nutritional significance of this diagnosis is great because disordered eating is very serious and can lead to malnutrition, stunted growth and development and vitamin and mineral deficiencies. b. Approximately two years ago in 2009, DB overheard his pediatrician say that he was 20 pounds over the normal weight for his age, and around the same time he was being teased at school and called fat in gym. Since that time, in which he was 116 pounds, he started losing weight. The next year, 2010, DB stated that the teasing at school was severe and that he thought that if he lost weight the teasing would stop. At that point he already lost about 20 pounds and his weight was approximately 95 pounds. DB s weight was approximately 87 pounds at the beginning of DB s pediatrician has been trying to promote weight gain, but to no avail, and therefore referred him to CNMC for inpatient admission for malnutrition and weight gain. DB s weight loss behaviors include becoming vegetarian, restricting calories at meals, self-induced

2 vomiting, and increased physical activity. These are the events which have led to the diagnosis of disordered eating pattern. During his hospital stay he was then diagnosed with confirmed Anorexia Nervosa. 2. Diet order: Eating Disorder Protocol a. The CNMC Eating Disorder (ED) Protocol is automatically initiated when a patient exhibiting eating disorder behavior or has been diagnosed with an eating disorder is admitted. The goals of the ED protocol are: nutritionally rehabilitate the patient and support growth, help the patient with conflict associated with food selection and consumption, enforce strict guidelines essential to patient s therapy/progress, and to take a multidisciplinary approach to treatment. The steps of the ED protocol are as follows: i. Determine when the patient was admitted and if the ED protocol has been ordered, specifically the diet order, which will be the Stage 1 Eating Disorder Diet. The amount of calories per day will be determined by the Attending physician. ii. Interview both patient and parents alone to obtain information on weight, food restrictions, physical activities, and use of laxatives or diet pills. Explain ED protocol and obtain 3 food dislikes that the patient is allowed to refuse. iii. Determine calorie goals. iv. Create menus for the patient based on recommended caloric intake. v. Make recommendations for intake, supplements, and monitoring of labs in the initial assessment note. b. Each meal will contain an equal amount of calories in which DB must eat within 30 minutes. The only foods that can be refused are the three dislikes, which are chicken, stuffing, and macaroni and cheese. If he does not consume all the food, he will be given Boost to make up the difference calorie for calorie. Another 15 minutes will be given to drink the Boost. If DB cannot finish the Boost, it will be given through the nasogastric (NG) tube. In addition, he will receive overnight NG tube feedings of Nutren 1.5. c. 5/18/2011: Stage calories per day (500 calories per meal). Nutren 40 ml /hr x 4 hrs, then 60 ml/hr x 4 hrs. d. 5/19/2011: Overnight NG feeds of Nutren 60 ml/hr x 4 hrs, then increase to 80 ml/hr x 4 hrs.

3 e. 5/20/2011: Stage calories per day (600 calories per meal). Increase to goal of Nutren 100 ml/hr x 8 hrs. This will provide an additional 1200 calories daily. f. 5/23/2011: Stage calories per day (600 calories per meal calorie snack). Overnight NG feeds of Nutren 100 ml/hr x 8 hrs. 3. Age: DB is 14 5/12 years old. He was full term at birth. 4. Weight 5. Height a. Corrected age: N/A DB was born full term so age correction is not necessary. b. Justify use of corrected age: N/A corrected age was not used. a. Percentile: < 3 rd b. Corrected weight percentile: N/A Weight did not need to be corrected. c. Weight age: 36.2 kg a. Percentile: 25 th b. Corrected height percentile: N/A Height did not need to be corrected. c. Height age: cm 6. Head Circumference: N/A Not measured in patients this age 7. Weight/Height Percentile: 3 rd percentile a. Rationale: Using this number is helpful when comparing the patient to himself to track and monitor growth. 8. Body Mass Index/percentile: 13.9 kg/m 2 (< 3 rd percentile) 9. Plot patient on growth chart: See growth chart a. The CDC growth chart for Boys ages 2 to 20 years was used, as it is recommended for all children over the age of 2 years. b. Evaluate: DB s growth in two days was remarkable. He gained 1.9 kg (4.18 lbs.). After nine days, DB gained 6.5 kg (14.3 lbs.) crossing a percentile. He went from <3 rd percentile to the 5 th -10 th percentile for BMI for age. 10. Estimated Requirements

4 a. Kcals/kg 79.0 kcal/kg/day b. Grams protein/kg 1.9 grams pro/kg/day c. ml/day to meet maintenance fluid needs 1824 ml fluid/day d. I determined these numbers based on: IBW x DRI x 1.5 activity factor/36.2 kg for calories and IBW x DRI of 0.95 x 1.5/36.2 kg for protein recommended. Calorie needs were increased because he is malnourished and appeared very thin. Protein needs were increased to encourage growth and to build lean body mass. Fluid needs were based on the Holiday-Segar method for fluid maintenance: > 20 kg = 1500 ml + 20 ml/kg for each kg > 20 kg. 11. Nutrition related medications reviewed: Yes. a. Potassium phosphate-sodium phosphate (Neutra-Phos) 1 packet, PO, BID to help prevent refeeding syndrome. Polyethylene glycol 3350 with electrolytes (MiraLax), 17 gm, PO, BID to help soften stool. Lorazepam0.95 ml to relieve anxiety. 12. Pertinent labs reviewed: Yes a. Available labs during assessment: Sodium result 134 mmol/l Potassium result 4.8 mmol/l HI Chloride result 99 mmol/l CO2 result 30 mmol/l HI Anion Gap 10 mmol/l Glucose Result 94 mg/dl BUN result 9 mg/dl Creatinine result 0.7 mg/dl Calcium result 9.3 mg/dl Phosphorus result 4.6 mg/dl Magnesium result 2.1 mg/dl Calcium, Ionized result 1.24 mmol/l b. Nutritionally significant labs: Phosphorus, magnesium, potassium, sodium and glucose. These labs are nutritionally significant because this patient is being monitored for refeeding syndrome. Initiating feeding after periods of starvation, which results in loss of body fat and protein and an accompanying depletion of potassium, phosphate, and magnesium, can lead to refeeding syndrome (1).

5 Assessment 1. Nutrition risk level: Complex II a. The nutrition risk of a patient with anorexia nervosa is high due to the nutritional rehabilitation that is necessary to help the patient regain weight. 2. Pertinent lab values: Potassium, phosphate, magnesium, and sodium should be monitored closely as this patient is at risk of refeeding syndrome. Refeeding syndrome can cause low levels of these minerals in the blood once feeding is initiated. Hypophosphatemia can cause heart failure, hypotension, muscle weakness, and hyperglycemia. Hypokalemia can cause cardiac arrest, respiratory failure, fatigue, diarrhea, nausea, and vomiting. Hypomagnesemia can present as respiratory distress, weakness, abdominal pain, and hypocalcemia. Hyponatremia arises due to hyperglycemia and can cause heart failure and arrhythmia, pulmonary edema, renal failure, and muscle cramps (1). 3. IV fluids: N/A DB is not receiving IV fluids. 4. Growth a. Rate of weight change: 722 grams/day weight gain over nine days. b. Appropriateness of growth: DB is gaining weight rapidly. This is normal for patients with anorexia nervosa who are now being nourished, as they are now gaining weight from fluid because they were dehydrated. Rehydration is important for maintaining electrolyte balance. c. Justify your assessment: I determined his rate of growth based on the difference in weight of the patient from day of admission to the last follow up which occurred nine days later kg kg = 6.5 kg x 1000 = 6500 g/9 days = 722 g/day 5. Diet prior to admission a. Adequacy of macro and micronutrients: Prior to admission DB ate a very restrictive, nutritionally inadequate diet. b. Adequacy of fluid: The fluid intake was also inadequate based on his diet history. c. Appropriateness of supplements: DB did not take any supplements prior to admission. d. Contribution of supplements to overall intake: N/A - DB did not take any supplements prior to admission. e. Justify your assessment: This assessment is based on DB s self-reported diet history of what he usually ate prior to being admitted to CNMC.

6 6. Diet order a. Adequacy of macro and micronutrients: The diet that DB is receiving as a part of the eating disorder protocol is not nutritionally adequate as he has not yet reached his goal intake as of 5/24/11. The diet order provided 1500 kcals and advanced to 2100 kcals per day of oral food and beverage. In addition, DB receives overnight NG tube feeds of Nutren 1.5 at 100 ml/hr for 8 hours that provided 1200 kcals. b. Adequacy of fluid: Fluid needs are adequate, as DB is getting the NG tube feeds of 800 ml plus flushes, water, juice, or milk with meals, and Boost if necessary. His electrolytes are balanced indicating that he is no longer dehydrated and is receiving adequate fluids. c. Appropriateness of supplements: DB s oral diet is being supplemented with Nutren 1.5. This means of enteral nutrition is appropriate in facilitating nutritional rehabilitation and supporting growth of the patient while in the hospital. d. Contribution of supplements to overall intake: The Nutren 1.5 is contributing 1200 kcals of total intake of 3300 kcals per day. e. Appropriateness of administration: The Nutren 1.5 is being administered through an NG tube at a rate of 100 ml/hr for 8 hours nightly. This method of administration is appropriate per the hospital eating disorder protocol. f. Justify your assessment: My assessment is based on the available data, the prescribed diet order and the eating disorder protocol that is followed very strictly. 7. Accuracy of data available: The available data presented in the chart appears to be accurate. Plans/Goals 1. Oral Nutrition: Continue with eating disorder protocol stage 1 diet: 2100 kcal/day (600 calories per meal plus a 300 kcal snack). If 100% of the meal is not eaten, supplement the uneaten calories with Boost (1 ml = 1 kcal). Offer first by mouth, and then if refused, give through the NG tube. 2. Enteral nutrition: Continue overnight NG feeds of Nutren 1.5 at a rate of 100 ml/hour for 8 hours. 3. Parenteral nutrition: N/A DB is not receiving parenteral nutrition. 4. Labs/Studies: Check BMP, Magnesium, and Phosphorus daily until levels are stable. Continue to monitor for refeeding syndrome. Continue to give NeutraPhos daily until risk for refeeding syndrome decreases.

7 5. Growth: Check patient s weight every Monday and Thursday. Goal weight gain should be grams per day. 6. Additional information needed: None. 7. Follow up: DB will continue to be followed-up every three days in the Adolescent Psychiatric Unit (APU) for further evaluation and treatment of his psychological issues that may be causing his disordered eating behaviors. Continue with the Maudsley family-based treatment (FBT) approach for anorexia nervosa. Once DB is released from the APU, I would recommend that he follow up on a regular basis with the dietitian at the outpatient eating disorder clinic to continue to receive treatment. 8. Justify your plan/goals: In terms of labs, it is important to monitor for refeeding syndrome to ensure that the patient is not being fed too quickly after a period of starvation. The key to managing refeeding syndrome is to to correct biochemical abnormalities and fluid imbalances returning levels to normal where possible (1). As far as treatment and follow-up, DB should continue with inpatient therapy until he is no longer underweight. This can be supported by data that suggests that discharged patients who are still underweight are more likely to have persistent or recurrent anorectic behavior, and they appear to exhibit greater psychiatric morbidity (2). The Maudsley FBT approach should be continued. Based on evidence from several studies, FBT appears to be the treatment of choice for adolescent anorexia nervosa, therefore, it should be the first line intervention (3). Studies also show that adolescents treated with FBT have a significantly better outcome than those treated individually after a year of outpatient treatment (3).

8 References: 1. Khan, LUR, Ahmed, J, Khan, S, MacFie, J. Refeeding Syndrome: A Literature Review. Gastroenterology Research and Practice. 2010;2011: Baran, SA, Weltzin, TE, Kaye, WH. Low discharge weight and outcome in anorexia nervosa. American Journal of Psychiatry. 1995;152: LeGrange, D. The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry. 2005;4: