Pediatric Case Study

University of Maryland College Park

Anastasia Maczko

Outpatient Pediatric Diabetes Case Study

Background
ZZ is a 15-year old male presented to the Diabetes Care Center on 03/09/15 for a follow-up
appointment related to a recent type 2 diabetes diagnoses in November 2014. ZZ was
accompanied by his father to the appointment, which was very supportive and indicated the
entire family has been making changes since diagnosis.
Subjective Information
1. Physical Appearance
a. ZZ presents with no visible wounds or injury during visit. Patient is ambulatory
with no acute distress.
2. Diet History prior to Admission
a. Feeding History No history of enteral or parenteral feeding.
b. Method of Feeding Patient eats by mouth. No additional mechanisms.
c. Oral/Enteral Intake
Formula N/A
Mixing Procedures N/A
Caloric Density N/A
Schedule N/A
Fluid Flushes N/A
WIC N/A
24-hour Recall or Typical Day
- Breakfast: crispix/cheerios cereal, whole milk, or school breakfast
provided with skim milk
Lunch (weekday): apple, chicken sandwich, soup, flavored water
Lunch (weekend, late bkfst): vegetables, peas, carrots, sausage
Afternoon snack: fruit (apple, banana)
Dinner: white rice, baked chicken, occasional pasta, water or
crystal light
- ZZ has eliminated chips, cookies, and sweets from the household
since diagnosis
- ZZ reports when he is with friends may have occasional soda or
share fries with them
Tolerance Issues no n/v/d/c
d. Vitamin or Mineral Supplements Medications only (Metformin and Levemir)
e. Food Allergies No allergies reported.
PES
1. Nutrition-related Diagnosis: Inconsistent carbohydrate intake related to timing of
carbohydrate intake and quantity as evidenced by repeated low blood sugar results (<50)
and meal gaps based off of dietary recall.
a. Justify Nutritional Significance

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Patient eats meals provided at school 1-2 times per day and options are
limited. The patient does not eat a snack after school or he will share fries
and have a soda with a friend. ZZ eats dinner with carbohydrates and
protein, but does not choose whole grains or include vegetables to keep
him full. The patient does not eat for 12+ hours from bed to morning
where his morning blood sugars have been repeatedly low.
b. Give Brief of Natural History of the Diagnosis
ZZ has had a long history of diabetic symptoms prior to his diagnosis four
months ago. ZZ was visiting relatives in El Salvador in the summer of
2013, when he became febrile and believed to have Dengue fever. The
patients blood glucose levels were checked while in El Salvador and
revealed to be 250. ZZ was strongly encouraged to visit his physician
when he returned to the United States. ZZ did not make an appointment
with a physician for seven months (April 2014) and reported experiencing
no diabetic-related symptoms appeared at that time. ZZ was given
paperwork to get blood work completed and glucose levels checked, but
had not done so until November of 2014. The patient was newly
diagnosed with type 2 diabetes, on November 22, 2014 at Childrens
National Medical Center (CNMC). At the time of ZZs diagnosis his
hemoglobin A1C was elevated at 14.2%. ZZs first meeting with the
endocrinologist was in December 2014. During the December visit, ZZ
weighed 197-lbs, down 27-lbs from his April 2014 visit due to increased
activity and healthy lifestyle. ZZ continued to follow-up with the medical
team in February 2015 at which time his weight increased to 211-lbs and
his hemoglobin A1C levels reduced to 7.4%. ZZ visited the Diabetes Care
Center on 03/09/2015 for weight management, at which time he weighed
218-lbs.
The American Diabetes Association released updated guidelines this year
and includes a regimen for testing children and adolescents for type 2
diabetes. Type 2 diabetes is more prevalent in ethnic populations, which
ZZ aligns with. The ADA suggests utilizing hemoglobin A1C as an
indicator rather than OGTT. Type 2 diabetes testing for adolescents
criteria includes overweight (>85th percentile), family history of type 2
diabetes, race/ethnicity, signs of insulin resistance, and maternal history.
ZZ meets criteria for family history, overweight, maternal family history,
race/ethnicity, and family history. ZZ would have benefited from an early
diagnosis by a physician at the time of his low blood sugar incidence in
2013. ZZ is now meeting with the weight management clinic in addition to
his endocrinologist team as an important part of managing the disease.
According to the ADA, nutrition therapy is recommended for both type 1
and type 2 diabetes patients and can result in cost savings and improved
outcomes (blood sugars and A1C levels).
2. Diet Order: ZZ is currently following a diabetic diet order. ZZ briefly was given
materials on carbohydrate counting, but according to endocrinology team may only need
oral medication if A1C continues to decrease.

3.
4.

5.

6.
7.
8.
9.

a. Aim for three meals with 75 grams carbohydrates and 1-2 snacks with 15 grams
of carbohydrates
Age: 16 years and 0 months
Weight = 99.1 kg
a. 99th percentile
b. N/A
c. Weight for age = 67.3 kg at 85th percentile
Height = 166.7 cm
a. 74th percentile
b. N/A
c. Height for age = 173 cm at 50th percentile
Head Circumference N/A
Weight/Height Percentile N/A
Body Mass Index/Percentile: 99th percentile
a. BMI = 35.7, obese, Z-score = 2.47
b. Using CDC BMI/age growth chart: Boys age 2-20.
Plot Patient on Growth Chart
a. Justify choice of growth chart
Patient is 16 years old and 0 months. The WHO growth chart is used for
children under two years of age. The CDC BMI chart is used for children
2-20 years of age per gender.
b. Evaluate patients growth
The CDC boy growth charts aged 2-20 were used to evaluate the patients
growth. ZZ plotted at the 99th percentile for his BMI for age, with a 2.47
z-score. ZZ plotted at the 19th percentile for stature for age, with a -0.89 zscore. ZZ plotted at the 99th percentile for weight for age, with a 2.33 zscore. Both his weight for age and BMI for age were elevated beyond the
growth curve.

10. Estimated Requirements

a. Mifflin St Jeor = 1,731 kcal/day 2,250 kcal/day
b. 0.85 g/kg protein = 85 grams/day protein

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c. mL/day to meet maintenance fluid needs = 3,082 mL/day
d. Justify how you determined these numbers
The patients calorie needs were determined using Mifflin St Jeor at ideal
body weight. Ideal body weight is determined using the BMI for age at the
85th percentile. Often ideal body weight is determined at the 50th
percentile, however, due to ZZs elevated percentiles, the 85th percentile is
a much more realistic goal. An activity factor of 1.3 was determined for
this patient because he is more active than a sedentary level. DRIs are used
for protein needs. Boys age between 14-18 recommend 0.85 g/kg/day.
ZZs energy requirements were determined using his current body weight
of 99.1 kg and the Holiday-Segar method.
11. Nutrition related Medications Reviewed
a. Metformin (1000 mg, 2x/day) oral medication to help control blood sugar
levels, may be used in conjunction with insulin.
b. Levemir (40 units, 0.41 units/kg) long-acting form of insulin used to treat type 2
diabetes.
12. Pertinent Labs Reviewed
a.
Hemoglobin CO2
BUN
Creatinine Total
HDL
LDL
Triglyceride
A1C
(mEq/L) (mg/dL) (mg/dL)
Cholesterol (mg/dL) (mg/dL) (mmol/L)
(mg/dL)
11/22/14 14.2% H
28
12
0.6 L
220 H
39 L
156 H
125
02/13/15 7.4% H
WNL
WNL
WNL
WNL
WNL
WNL
WNL
b. Hemoglobin A1C: used to diagnose type 1 and type 2 diabetes and monitor the
management of the diagnosis. ZZ had an hemoglobin A1C above 14% at the time
of diagnosis. With four months, the patient was able to cut his A1C levels in half.
Hemoglobin A1C is a reflection of the average blood sugar over the past 2-3
months utilizing the protein in red blood cells.
c. Cholesterol: reflects the plaque formation build up in the arteries. Cholesterol is
found in high-fatty foods and is linked with type 2 diabetes. Diabetic patients are
at an increased risk of developing cardiovascular disease and studies recommend
a goal even lower than the normal recommendation of <70 mg/dL for LDL and
total cholesterol less than 200 mg/dl. ZZ had elevated levels at the time of
diagnosis, but both of these values were within normal limits in February 2015.
d. ZZ recorded blood sugar values in morning averaging between 50-60 mg/dL.
Assessment
1. Nutrition Risk Level
a. Patients nutrition risk level is currently low. Patient has made drastic changes
since his diagnosis. Although his weight increased since diagnosis his blood
sugars and A1C have reduced drastically. ZZ demonstrated good compliance and
has moved his nutritional goals to including physical goals as well. ZZ also rated
himself as a 7 on his ability to accomplish his goals. ZZ has a strong support
system at home and the entire family has actively made positive changes.
2. Pertinent Lab Values

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a. Patients lab values are within normal limits. Will continue to monitor blood
sugars and consult with physician as needed to reduce very low blood sugars in
the morning.
3. IV Fluids N/A
4. Growth
a. Rate of weight change
Date
Weight (kg)
Change
04/02/14
101.2 kg
N/A
11/22/14
N/A
N/A
12/03/14
89.3 kg
-11.9 kg
02/13/15
95.8 kg
+6.5
03/09/15
99.1 kg
-3.3
Overall -2.1 kg
b. Appropriateness of growth
ZZs weight has fluctuated since diagnosis decreasing rapidly initially, and
then slowly increasing. ZZ began a vigorous exercise regimen prior to
diagnosis and lost weight suddenly, which can often lead to weight gain if
the process is not a healthy regimen that is realistic. During the counseling
session, RD discussed incorporating exercise as part of a normal routine.
c. Justify your assessment
The patients rate of weight change has fluctuated over the past 11
months. ZZ was at his highest weight when his diabetes was first
suspected at 101.2 kg (04/02/14). ZZ lost 26 pounds over the course 7
months at his lowest weight of 89.5 kg (11/22/14). Since beginning insulin
and medications his weight has slowly trended upward to his most recent
weight of 99.1 kg (03/09/15). ZZ attributes the slow weight gain related to
his decrease in activity level during the winter months. ZZ lost weight
with an active running schedule, 2 miles per day. At the most recent visit
ZZ set goals to begin a more active lifestyle.
5. Diet prior to Admission
a. Adequacy of macro and micronutrients
According to the estimated energy and protein requirements for a 16-year
old male using Mifflin St-Jeor, ZZs calorie needs are around 2,250
calories per day and 85 grams of protein per day. ZZs estimated calorie
intake on a typical school day is 1,668 calories, 78 grams of protein, 29
grams of fat, and 231 grams of carbohydrates. Based on ZZs dietary
recall, he is meeting 74% of his calorie needs and 92% of his protein
needs.
b. Adequacy of fluid
Based on the Holliday-Segar Method, the patients fluid intake should be
around 3,082 mL per day. According to ZZs dietary recall, he is
consuming about 1,660 mL of fluids per day, meeting just 53% of his
needs.
c. Appropriateness of supplements N/A
d. Contribution of supplements to overall intake N/A

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e. Justify your assessment
The patients energy and fluid needs were estimated using the USDA
nutrition facts and the school lunch menus nutrition information available
online for both breakfast and lunch. Assessing the adequacy of ZZs diet
history is challenging because he did not know exact portion sizes.
Additional calories were added for French fries that he occasionally shares
with friends. ZZ often experiences drops in blood sugar levels in the
morning that may be helped with a late-night snack.
6. Diet order
a. Adequacy of macro and micronutrients
Based on ZZs dietary recall and support system at home. We discussed
increasing fruits and vegetables in his diets to balance meals. We also
discussed adding a late night snack to help correct continued low-blood
sugar.
b. Adequacy of fluid
ZZ has eliminated sugary beverages and soda from his diet most of the
time, but does have an occasional soda. We encouraged ZZ to carry a
water bottle with him at school to stay hydrated and drink extra water
during and after physical activity. ZZ drinks skim milk when he is at
school
c. Appropriateness of supplements N/A
d. Contribution of supplements to overall intake N/A
e. Appropriateness of administration N/A
f. Justify your assessment
ZZ has shown great strides since his diagnosis eliminating junk food,
sweets, and soda from the house. Both his father and mother are involved
and encouraging the entire family to eat more fruits and vegetables and
balance their meals.
7. Accuracy of data available
a. The data above is gathered from the patients visit with the Registered Dietitian,
Nurse Practitioner, and Endocrinologists records. Nutrition information is
gathered from the patients visit at the Diabetes Care Complex visit with his
father.
Plan/Goals
1. Oral Nutrition Diabetic Carbohydrate Controlled Diet, focus on MyPlate and balancing
meals.
2. Enteral nutrition N/A
3. Parententeral nutrition N/A
4. Labs/Studies N/A
5. Growth Increased weight since last visit. Overall weight since diagnosis is lower. ZZ is
categorized as severe overweight.
6. Additional information needed
a. Aim to move at least 30 minutes per day (strength training, Wii fit, walk/run)
everyday.

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b. Track completion of physical activity 30 minutes per day using a calendar
checking system.
c. Try to increase fruits and vegetables to 4-5 per day. Include fruit or vegetable at
every snack time.
d. Adjust morning insulin and/or add late night (8-9 pm) snack to avoid morning
blood sugar dip.
7. Follow up in 2-3 months.
8. Justify your plan/goals
a. ZZ has made substantial changes in his diet since November diagnosis and
believes now is the time to improve on his physical activity regimen to help with
weight loss.
References
1. A1C Test. Mayo Clinic Website. http://www.mayoclinic.org/tests-procedures/a1ctest/basics/definition/prc-20012585. Accessed March 14, 2015.
2. American Diabetes Association. Nutrition principles and recommendations in diabetes.
Diabetes Care. 2004; 27 (1): S36. DOI: 10.2337/diacare.27.2007.s36.
http://care.diabetesjournals.org/content/27/suppl_1/s36.full
3. American Dietetic Association. Position of the american dietetic association: weight
management. J Am Diet Assoc. 2009; 109 (2): 330-46. DOI: 10.1016/j.jada.2008.11.041.
http://www.andeal.org/files/files/WeightManagement.pdf
4. Cefalu WT, et al. Standards of medical care in diabetes - 2015. Diabetes Care. 2015; 38
(1): S20-31. DOI: 10.2337/dc15-S001.
http://professional.diabetes.org/admin/UserFiles/0%20%20Sean/Documents/January%20Supplement%20Combined_Final.pdf
5. About Cholesterol. American Heart Association Website.
http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/AboutCholesterol_UCM_001220_Article.jsp. Accessed March 14, 2015.