Interdisciplinary Case Study: A 12 year old with OSA

Interdisciplinary Case Study:
A 12 year old with OSA
Mary Halsey Maddox, Sleep Fellow
Julianna Bailey, Nutrition Trainee
Claire Lenker, PPC Social Worker
Mary Halsey Maddox
Initial Contact
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
Depression with suicidal ideation – history
of psych admit in 2005 for aggression
Seasonal allergies
Multiple missed visits with sleep center
and weight management
Family History
Sleep Apnea
Learning Disorders
Bipolar Disorder
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
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
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
Mild secondary pulmonary hypertension
Recommended treatment – treat OSA
Tolerated procedure well
Continued CPAP +12cm H2O
Follow Up NPSG
Weight – 241.4 pounds, Height – 60.4
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
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
 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
M’s diet recall does not include late night
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
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
 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
 Repeated no-show to WM appointments, did not
Nutrition Plan
 Praised Mom for positive, family-centered
 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?
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
 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
 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
 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
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
 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
All electric utilities
S & J share a room
M & T share a room
Children attend
Bessemer City
changed to “where
they’re supposed to be”
Family Resources
 Mom has a truck for
 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
 ADPH SW now helping
mom with Medicaid
NETS reimbursement
 Mom keeps a folder
with appointments and
other information
 IN
M: SSI of $674/month
D: SSI of $674/month
Food Stamps
Mom’s unemployment
of $56/week recently
No child support
Rent $217/month
(Section 8)
Power Bill: between
$414 and $690 per
No car payment
No other recurring
“We manage”
Family Health Issues
 Mom describes herself
and all 5 children as very
 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
 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’ Health Issues
 T – medical record: DOB 11/5/99
 No show to Wt Mgmt 1/8/10
 enuresis and encopresis noted in
 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
 ENT post op appt 11/29/10: doing
better on CPAP, needs Wt Mgmt
 No show to Urology f/u 11/30/10
 No show to GI 12/15/10
 Currently has NO scheduled
 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
 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.
 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
 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
 Mom appears motivated
 however chronic no
shows for multiple
children with multiple
 Good relationship with
 SW at ADPH helping with
Medicaid NETS
 Live close to specialty
 Dad helps with school
 No significant financial
 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
 School
 Out of zone right now
 M is failing
 Threat of expulsion due to
 No real plan for supports at
 No care coordination for M, T, &
 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
 Consider family
appointments for both
Weight Management
Clinic and Sleep/CPAP
 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
Nutrition Questions and alternative
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!