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 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 Medications Albuterol Family History 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 Visit 8/24/10 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 NPSG 8/25/10 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 noncompliance) Cardiology Evaluation 9/2/10 Mild secondary pulmonary hypertension Recommended treatment – treat OSA Adenotonsillectomy 9/7/10 Tolerated procedure well Continued CPAP +12cm H2O Follow Up NPSG 11/10/10 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 4045. 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 extracurricular 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 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!