Pediatric Case Study: Anorexia Nervosa Presented by: Colleen Abbott
Background
* A.T. from the Dominican Republic * A.T. attends a ballet school on scholarship in DC * Over Christmas break, mom noticed patient reducing intake at meal times and no longer eating dessert. * At Spring break patient had eliminated certain foods * Peanut butter * Seen by her PCP, Psychologist, and Endocrinologist and was diagnosed with anorexia nervosa.
* Returned to DC with mom and school nurse referred patient to psychiatry here at CNMC.
Background * A.T. reports restrictive eating began as a desire to “be healthy” * She wanted to look “better and thinner for ballet” * Begin restricting food * Sweets and carbohydrates
* Increased exercise * Added an extra hour of weight training and core exercises in addition to 3-‐4 hours of daily ballet practice. * Patient was told she should “look like a noodle, not eat noodles.”
Family History
* As a small child the patient enjoyed her meals and was taught to respect meal time. * Ate a traditional Latin diet * A.T.’s stepfather is an Italian and owns an Italian restaurant.
* Mother: bulimic as an adolescent * Maternal Grandmother: restrictive eating/dieting * No formal diagnosis of an eating disorder
Diagnosis
* Dr. Silber diagnosed A.T. with anorexia nervosa and recommended inpatient hospitalization. * Anorexia Nervosa * * * *
BMI: 16.2 Heart rate concerning for bradycardia Amenorrhea x3 months 18 lb. (16%) weight loss in 4 months
Anthropometrics Age: 16 years 5 months old Admission: 4/10/15 Weight
40.5 kg
Percentile
1%ile
Z-‐score
-‐2.34
Height
158 cm
Percentile
23%ile
BMI
16.22
Percentile
2%ile
Z-‐score
-‐2.14
IBW
50 kg
%IBW
82%
Medications
* Prior to Admission * Calcium * Vitamin D * Multivitamin
* Inpatient * PhosNaK * Multivitamin
Lab Values
4/15/15
4/13/15
4/11/15
4/10/15
Na
142
142
143
144
K
4.0
3.9
3.9
3.8
Cl
107
106
106
104
CO2
28
22
27
28
Glucose
88
71
73
97
BUN
18
13
15
16
Cr
0.7
0.7
0.8
0.8
Ca
8.8
8.9
8.7
9.4
Phos
3.9
4.2
4.5
3.7
Mg
2.3
2.4
2.3
2.4
4.5
Albumin
Re-‐feeding Syndrome * Hypophosphatemia (< 3.0 mg/dL) * Hypomagnesemia (< 1.7 mg/dL) * Hypokalemia (< 3.5 mg/dL) * These lab values can be normal at admission can drop once feeding occurs. The theory behind re-‐feeding syndrome is the electrolytes shift from extracellular to intracellular spaces with re-‐feeding, stimulated by insulin secretion in response to reintroduction of carbohydrate.1 * This patient did not appear to develop re-‐feeding syndrome * Received PhosNaK upon admission
Nutrition Visits
* Initial Assessment 4/11/15 * Follow-‐up 4/13/15 * With mom
* Follow-‐up 4/15/15 * Discharge meal plan
* Follow-‐up 4/16/15 * New measured weight
PES Statement
* Oral food/ beverage intake inadequate (NI-‐2.1) related to restrictive eating as evidence by 16% weight loss x 4 months. * High Nutrition Risk
Estimated Needs
* Energy: 61 kcal/kg/day * DRI based on age, multiplying by an activity factor of 1.5 for weight gain, multiplied by ideal body weight and divided by current body weight
* Protein: 1.6 g/kg/day * DRI based on age, multiplying by an activity factor of 1.5 for weight gain, multiplied by ideal body weight and divided by current body weight
* Fluid: 1916 ml * Holiday-‐Segar Method
Diet Order 4/11: 1500 kcal/day: 500 kcal/meal x 3. Enteral nutrition support via NG tube: Nutren 1.5 @ 60 ml/hr; advance by 20 ml q 4 hours as tolerated to reach goal of 100 ml/hr x8 hours overnight.
4/13: 1800 kcal/day: 600 kcal/meal x 3. Enteral nutrition support via NG tube: Nutren 1.5 @ 100 ml/hr x8 hours overnight. 4/15: 2400 kcal/day: 700 kcal/meal x 3 + 300 kcal snack. Enteral nutrition support via NG tube: Nutren 1.5 @ 100 ml/hr x 8 hours overnight
High Caloric Diet Research
* According to Golden and colleagues1 starting patients on an average of 1550 kcal/day diet * Associated with a reduced length of stay * Did not experience increased rates of hypophosphatemia, hypomagnesemia, or hypokalemia * Re-‐feeding syndrome
* Results in decreased healthcare costs and allows the adolescent to return home sooner to family-‐based treatment.
Inpatient Recommendations * Continue on eating disorder diet * Continue Multivitamin, PhosNaK * Check basic metabolic panel, Magnesium, and Phosphorous daily * Measure 25-‐hydroxy D * Measure blind weight 2x week: Monday, Thursday * Goal weight gain 250-‐300 g/day
* Monitor for regular bowel movements * Provide regiment as needed
4/16/15
4/13/15
4/10/15
Weight Gain Since Admission
40.5 40.8 43.5 kg kg kg
* Patient gained 3 kg; averaging 500 grams per day. * Goal 250-‐300 grams per day.
* According to Le Grange and associates2 early weight gain through parental efforts seems to have a positive impact on remission status.
Discharge Plan
* A.T. completed one supervised meal with mom in the hospital cafeteria. * Mom decided to stay in DC to supervise A.T. * Patient will continue to follow up with Dr. Silber & Spring Valley Eating Disorders Clinic.
Discharge Recommendations * A.T. has the responsibility of eating and the caregiver has the responsibility of providing a variety of foods. * A.T. can only state dislikes once a week. * Limit low-‐fat & non-‐fat foods. * A.T. must be supervised at meals. * Caregiver is not to disclose number of servings or number of calories, and all package foods need to be removed when served. * Only caregiver is to do the grocery shopping and cooking.
Discharge Meal Plan
Breakfast
Lunch
Dairy
1
1
Grains
3
3
Protein (oz.) Fruits
2
3 oz. 1
Vegetables Fat
Snack
Snack
Total
1
1
4
3
2
13
4 oz. 1
1 2
Dinner
1
7 oz. 1
2 1
2
3 3
2
8
References * 1. Golden NH, Keane-‐Miller C, Sainani KL, Kapphahn CJ. Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome. J Adolesc Health. 2013; 53: 573-‐578. * 2. Le Grange D, Accurso EC, Lock J, Agras S, Bryson SW. Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa. Int J Eat Disord. 2014; 47(2): 124-‐129. * 3. American Academy of Pediatrics. Pediatric Nutrition Handbook. United States of American; 2003.
Questions? Thank you