Pediatric Nutrition Internship

Intern: _Andrea Belloli___

Written Case Study- Evaluation Format for Interns and Preceptors

Subjective:
1. Physical Appearance
a. Overweight, timid 10 year old girl with evidence of acanthosis nigricans around
neck, elbows, and armpits.
2. Diet History prior to admission
a. Feeding History- no feeding problems, eats regular diet PO.
Prior to seeing the RD for weight management, patient was consuming
large amounts of sugar-sweetened snacks and beverages and eating
large portions.
Since beginning to see the RD, patient has reduced portion sizes,
switch to water and skim milk as only beverage options, and has begun
eating healthier, more balanced meals.
b. Method of feeding- pt receives all nutrients PO.
c. Oral/Enteral Intake
Specific formula-n/a, pt consumes normal PO diet
mixing procedures- n/a
caloric density- n/a
schedule-n/a
fluid flushes- n/a
WIC- n/c, did not obtain this information at time of visit.
24 hour recall or typical day (recall from 3/24/15)
1. Breakfast (7:40 am): glass of skim milk and bowl of whole grain
cereal with fruit or whole grain waffle with honey
2. School Lunch (12:15 pm): hotdog/chicken nuggets/grilled
cheese/chicken patty sandwich/pizza with either an orange or an
apple and bottled water
a. If she packs a lunch, she will eat a tuna sandwich with
lettuce and tomato on wheat bread or a turkey/ham
sandwich with lettuce and tomato on wheat bread.
3. Afternoon snack at school (between 3-5pm): bottled water and
either cheese crackers, string cheese, yogurt, or a cereal bar
4. Dinner (between 5:30-6pm): salad with chicken cooked in iron
skillet or grilled/baked fish or a tuna sandwich
5. After dinner snack (7:30 pm): bananas or blueberries with low-fat
yogurt or bowl of cereal with skim milk.
Tolerance issues (nausea/vomiting/diarrhea/constipation)
1. No recent complaints of nausea, vomiting, diarrhea, or
constipation.
Any other relevant information
1. Eats breakfast and dinner at home with family
2. Eats lunch and afternoon snack at school
3. Pt struggles with portion size
d. Vitamin or Mineral Supplements Vitamin D 2000 IU daily

Pediatric Nutrition Internship

Intern: _Andrea Belloli_
e. Food Allergies-NKA
PES:
1. Nutrition-related diagnosis- Obesity and hyperlipidemia, mixed
a. Overweight, pediatric (NC-3.3.1) related to mild autism and self-monitoring
difficulty as evidenced by BMI of 27.3 and BMI-for-age in the 98th percentile.
b. Justify nutritional significance
i.
Being overweight and having mixed hyperlipidemia puts her at an
increased risk for developing cardiovascular disease (CVD).
ii.
Obesity also puts the patient at risk for developing type 2 diabetes,
bone and joint problems, social and psychological problems, and sleep
apnea.
(Kools, Kennedy, Engler & Engler, 2008, p. 168)
c. Give brief of natural history of the diagnosis
2. Diet Order- n/a, patient seen in outpatient general nutrition clinic
3. Age- 10 years 6 months
a. DOB 09/24/2004
4. Weight- 64.6 kg
a. Percentile- greater than 97th percentile
5. Height- 153.8 cm
a. Percentile- 96th percentile
6. Head Circumference- n/a
a. Percentile- n/a
b. Corrected head circumference percentile- n/a
7. Body Mass Index- 27.3
a. Percentile- 98th percentile
8. Plot patient on growth chart
a. Justify choice of growth chart- Used CDC growth charts for gender and age
because the patient is greater than 2 years old.
b. Evaluate patients growth
i.
Although patient is tall for her age, her BMI is above the 98th
percentile indicating that she is obese.
ii.
Since October, patient has lost 7.26 lbs and has grown 3.3 cm, thereby
decreasing her BMI. This is shown by a slight decline in the patients
BMI-for-age chart.
iii. The patients height seems to be following the normal growth curve.
9. Estimated Requirements
a. 33 Kcals/kg (IBW)
b. 0.95 Grams Protein/kg
c. 2390 mL/day to meet maintenance fluid needs
d. Justify how you determined these numbers
i.
I used the patients IBW (48 kg) to determine her estimated energy
needs
ii.
Estimated fluid requirements based on Holiday-Segar method
10. Nutrition related Medications Reviewed
a. No known nutrition-related medications
11. Pertinent Labs Reviewed (labs from 10/25/14)

Pediatric Nutrition Internship

Intern: _Andrea Belloli
a. Include labs available when assessing this patient
i.
Total cholesterol 145 mg/dL
ii.
Triglycerides 193 mg/dL (high)
iii. HDL 36 mg/dL (low)
iv.
VLDL 35
v.
LDL 74
vi.
HbA1c 5.2%
vii.
Vitamin D 12.3 (low)
viii. Insulin 31.1 (high)
b. Note labs deemed to be nutritionally significant and justify why
i.
The patients elevated triglyceride level is nutritionally significant
because it can be directly related to the health status of the patient.
Elevated levels of triglycerides are associated with an increased risk of
developing heart disease.
ii.
Low HDL levels are also associated with increased risk of heart
disease. HDL levels can be lowered by making lifestyle changes such
as increasing physical activity.
iii. Low vitamin D levels put the patient at risk for cardiovascular disease
and could play a role in glucose tolerance.
iv.
High levels of serum insulin are indicative of insulin resistance. This
can be linked to the patients obesity.
Assessment:
1. Nutrition risk level- Low Risk
a. Justify choice of risk level- Patient is at low nutritional risk. She is eating
properly, growing at a normal rate, and losing an appropriate amount of weight.
Follow-up appointments should be scheduled every 3 months to assess weight
and growth.
2. Pertinent Lab valuesa. Justify their relationship to nutrition/hydration status
i. High triglycerides- Elevated levels can be due to high-calorie diet or one
that is high in saturated fat, trans-fat, or cholesterol; being physically
inactive, overweight, or obese; and genetic factors.
ii. High levels of serum insulin are indicative of insulin resistance. This
can be linked to the patients obesity. Insulin resistance puts the patient
at risk for developing diabetes.
b. Patient was encouraged to get new lab work completed between now and her
next nutrition appointment since previous labs were from October 2014.
Patients mother was instructed to bring new lab results to the next meeting.
3. IV fluids- n/a, patient not on IV fluids
4. Growth
a. Rate of weight change- Patient is losing weight at a rate of 3.75 lbs per month.
b. Appropriateness of growth- according to her height-for-age growth chart, the
patient is tall for her age and growing appropriately.
c. Justify your assessment- Patient is growing well and losing the weight necessary
to lower her BMI towards the 95th percentile.
5. Diet prior to admission (Based on 24 hour recall from 3/24/15 listed above)

Pediatric Nutrition Internship

Intern: _Andrea Belloli_
a. Adequacy of macro and micronutrients
i. Based on patients 24 hour recall, she has been making some healthy
adjustments to her diet. For example, she has switched from drinking
2% milk to skim and all of her breads, cereals, and starches are whole
grains. All juice has been replaced with water or skim milk. And
although she sometimes eats the school lunches consisting of either
chicken nuggets or pizza and fruit, the patients mother has been packing
her lunches more frequently.
ii. Although I do not have the actual number of grams consumed each day,
it seems as though the patient is consuming an adequate amount of
protein each day.
iii. Patients diet is a little high in carbohydates. Spoke with mother about
packing a non-starchy vegetable or low-fat dairy product instead of the
cereal bars for her afternoon snack at school
b. Adequacy of fluid
i. Patients fluid intake seems appropriate for her age and size. She
consumes one water bottle or cup of milk with each meal and snack.
c. Appropriateness of supplements- n/a- patient doesnt consume supplements
d. Contribution of supplements to overall intake- n/a
e. Justify your assessment
i. Assessment based on both the 24-hour recall and conversations with the
mother and daughter.
6. Diet order- N/A, pt seen in outpatient general nutrition clinic
7. Accuracy of data available
a. Since most of the data was collected by talking to the patients mother, some of
the 24 hour recall may not be completely accurate.
b. The amounts and exact types of foods are not known, therefore we are unsure
about the macro and micronutrient intake.
c. The mother and patient could be lying to the RD and simply telling her what
they think she wants to hear (bias).
d. Lab results were from October 2014. Since patient has been losing weight by
eating healthier and increasing physical activity, some of these results may have
changed.
e. Weight and height were accurate. Same scale and measuring protocol is used at
each visit.
f. Pts mother spoke little English and interpreter services were used. Answers to
some questions may be skewed if interpreter imposed their own opinions into
the translations.
Plan/Goals:
1. Oral nutrition- Pt will eat a healthier balanced snack consisting of:
a. Fruit/non-starchy vegetable
b. Whole grain and a lean protein source
c. Low-fat dairy, such as yogurt or string cheese
d. Limiting cereal bars
e. Provided patient with handouts on 100 calorie snacks and other healthy snack
ideas in both Spanish and English.

Pediatric Nutrition Internship

Intern: _Andrea Belloli
2. Enteral nutrition-n/a, pt consumes all nutrients PO
3. Parenteral nutrition- n/a, pt consumes all nutrients PO
4. Physical Activitya. Starting in April, pt will do swimming on Tuesdays and Thursdays.
b. The other 5 days of the week, pt will ride bike outside for one hour.
c. Rainy day activity: Wii, Just Dance for 30 minutes-1 hour.
5. Labs/Studies
a. Patient will get new labs drawn between now and next visit with RD in 3
months.
b. Goal is for patients triglyceride levels to decrease and HDL levels to increase.
6. Growth
a. Patient will continue to grow along growth curve.
7. Additional information needed- n/a
8. Follow up
a. Pt will follow up with RD in general nutrition clinic in 3 months to assess
weight, height, and compliance with nutrition-related goals.
9. Justify your plan/goals
a. It is important to designate one of the patients 3 goals to physical activity to
assist with further weight reduction. Impairments specific to autism as well as
environmental factors could lead to an imbalance between the intake and
expenditure of energy making it easy for the patient to become overweight.
(Srinivasan, Pescatello, Bhat, 2014, p. 875)
b. RD utilized motivational interviewing techniques to get patient to set her own
realistic, SMART goals. By creating her own goals, the patient will be more
motivated to fulfill them.
c. By adjusting her snacks and increasing physical activity, the patient should
continue to lose weight at a healthy rate.

Pediatric Nutrition Internship

Intern: _Andrea Belloli_
References
Academy of Nutrition and Dietetics (n.d.). Autism spectrum disorders. Retrieved March 29, 2015 from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=255327&nc
m_heading=Nutrition Care&ncm_content_id=110025#Overview.
Academy of Nutrition and Dietetics (n.d.). PMW: Determining energy needs in overweight children
and adolescents. Retrieved April 1, 2015 from http://www.andeal.org/topic.cfm?cat=3060
Academy of Nutrition and Dietetics (n.d.). Overweight and Obesity. Retrieved March 29, 2015 from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=16997&nc
m_heading=Nutrition Care&ncm_content_id=79432#DiagnosticTests.
Kools, S., Kennedy, C., Engler, M., Engler, M. (2008). Pediatric hyperlipidemia: Child and adolescent
disease understandings and perceptions about dietary adherence. Journal for Specialissts in
Pediatric Nursing, 13(3), 168-179.
Srinivasan, S. M., Pescatello, L. S., Bhat, A. N. (2014). Current perspectives on physical activity and
exercise recommendations for children and adolescents with autism spectrum disorder.
Physical Therapy Journal, 94(6), 875-889.