Adolescent Malnutrition

A case study written by:

Lea Palmer
Patient Overview

Pt was a 17 y.o. Caucasian female

Admitted from with endocarditis r/t bicupsid aortic valve

and chronic IVDU. TPN was initiated at OSH but was DC PTA.

In hospital:
Acute hemorrhagic and ischemic CVA requiring decompressive
craniectomy and blood clot removal
Refeeding Syndrome

Nutritional diagnosis: Severe chronic protein-energy

malnutrition
 Patient History
Medical:
Chronic: Bicuspid aortic valve & 3 years IVDU Endocarditis
11/2013: head trauma brain concussion
03/ 2015: Threatened abortion
11/15: Traumatic but successful labor

Social:
Parents unmarried- co-parenting appropriately
Mother- Ovarian cancer survivor
Inconsistent living conditions
9 month old son with CF
7th grade education
Smokes 3-4 cigarettes/day
 Pediatric Malnutrition1

2013 ASPEN definition: an imbalance between nutrient

requirements and intake, resulting in cumulative deficits of
energy, protein, or micronutrients that may negatively affect
growth, development and other relevant outcomes.
Illness related (Crohns, CF, cancer, etc.)
Environmental/behavioral related
Assessing for Malnutrition1

Needs to be quantifiable
Anthropometrics- Wt, Ht/length, BMI, MUAC, TSF, OSF, Z-
scores
Growth History
Chronicity
Etiology
Addresses inflammation
Impact on functional status
 Severity of Malnutrition
Decreased quality of life

Poor physical growth

Increased length of stay

Poor wound healing

Impaired immune function

 Risk Factors

Indications of malnutrition:
Chronic heroin abuse delayed gastric emptying,
dysfunctional eating patterns low body weight, nutrient
deficiencies Malnutrition
Hemorrhagic and Ischemic CVA dysphagia, altered
mental status
Adolescent pregnancy poor dietary habits, increased
nutrient needs
Refeeding Syndrome after TPN initiation
 Anthropometrics
Weight Hx
Ht: 161
55

UBW: 52 kg
50

IBW: 53 kg
45
%IBW: 71-
Kilograms
86% 40

BMI: 14.4-
17.6 35

No MUAC 30
Usual Body Wt 12-Aug 5-Sep 12-Sep 16-Sep 2-Oct
Anthropometric Z-scores2

UBW: 52 kg; z-score= -0.46

Previous wt (9/8) 44.4 kg. 4%ile for age; z-score=

-1.77 (MILD)

Current wt (9/16) 43.3 kg, 2%ile for age; z-score=

-2.01 (MODERATE)

Ht for age: 161 cm, 38%ile; z-score= -0.32

BMI: 16.7 kg, 2%ile, z-score= -2.10 (MODERATE)

 Lab Value Trends
Refeeding syndrome periods:
Low: phosphate (5.3), potassium (2.8), magnesium (1.5)
High: Glucose(223), BUN (26), Sodium (159)

Malnourished Indicators
Low: Vit D (21), Zinc (25), calcium (7.5)

Inflammation:
High: CRP ( ranging 9.7-25)
Low; Alb (2.3)

After vitamin supplementation and slowly increasing feeds, all levels

returned to normal ranges, except CRP
 Current Medications
For muscle relaxing/ anti-seizures: Keppra, Gabapentin, Baclofen

For pain relief: Tylenol, oxycodone, clonidine

For anti-hypertension: Clonidine, Carvedilol, Spironolactone

For depression: Citalopram, Gabapentin

For gut health/relief: spironolactone, lactobacillus, omeprazol,

miralax

For refeeding syndrome/malnutrition: calcium gluconate,

magnesium sulfate, potassium chloride, cholecalciferol, zinc
elemental
Potential Drug-Nutrient Interactions3

Alcohol Keppra, Citalopram, Melatonin, oxycodone,

gabapentin, tylenol, baclofen, carvedilol,
spironolactone

Natural Licorice Clonidine, Carvedilol, Spironolactone

Citrus Oxycodone
Clinical Findings

Per OT evaluation
Head- head shaven, incision clean and dry
Nails: Blue/Black tint
Skin: Tissue necrosis in extremities, embolic phenomena
Muscles/fluid: muscle wasting, knees swelling
Eyes: right eye swollen shut, left eye swollen but can open
Dietary

Extensive history of diet orders

Admit regular diet EN (refed) NPO TPN Trophic+
TPN Vivonex continuous Peptamin Prpio continuous
NPO for surgery Peptamin continuous Current order

Current order:
Bolus Peptamin Prebio 1.0 q3 hours x 5 daily run over 2
hours, condense to 1 hour as tolerated
Total Fluid: 410 ml
Supplemental zinc elemental, MVI
Malnutrition Nutritional Risk

Chronicity: Pathogenic:
Chronic (>3 months)
Starvation/ decreased
Acuity nutrient intake
Moderate- Severe (z-scores
-2 to 3) Inflammation: present
CRP levels: ranging
Etiology
from 9.7 to 25
Illness related: CVA
Behavior/ socioeconomic Physical Exam
related- inconsistent living
Muscle Wasting
arrangements, chronic
IVDU, adolescent
pregnancy
Nutrition Diagnosis

Severe chronic protein-energy malnutrition related to

inadequate oral intake in the setting of dysphagia s/p
CVA, chronic IVDU, and adolescent pregnancy as
evidenced by tube feed dependence.
Intervention

Medical:
Work with speech pathologist to develop
chewing/swallowing motor skills
Continue work with PT/OT to improve ADL capabilities

Nutrition:
100% of bolus feeds (Peptamin w/ Prebio, 410 ml 5 x/day),
while attempting PO with speech pathologist.
Provides 2050 kcal, 2050 ml fluid, and 2.0 g/kg protein.
Goals

Consume adequate nutrition to promote appropriate

weight gain (IBW: 53 kg)

Condense feeds to 1 hour as tolerated

Improve oral motor skills enough to begin PO

Evaluation and follow up

If patient is tolerating feeds in 1 week, continue with

same recommendations.

If patient has improved oral motor function, encourage

increased PO in one week while continuing bolus feeds.
 Note per PCH
Pt is a 17 Y 7 M adolescent female w/ PMH of acute malnutrition, heroin use, w/ MSSA endocarditis found
to have acute hemorrhagic and ischemic stroke s/p clot removal and bone flap.
Anthropometrics:
UBW: 52 kg; z-score= -0.46
Previous wt (9/8) 44.4 kg. 4%ile for age; z-score= -1.77
Current wt (9/16) 43.3 kg, 2%ile for age; z-score= -2.01
Ht for age: 161 cm, 38%ile; z-score= -0.32
BMI: 16.7 kg, 2%ile, z-score= -2.10
Wt history:
Acute: Wt loss x 8 days: 1.1 kg= 3% wt loss
Net wt change since admit: 5% wt loss
Extreme daily wt variance (6.5 kg gain > 2 days) is likely due to scale errors and fluid change.
Chronic: Wt loss of 14% x 5 months
Expected wt gain for age: 6-9 g/day

Nutrition Assessment: Formula changed and pt is currently tolerating feeds well. Pt is beginning to
stabilize but is still losing wt and is now 95% of admit wt. Currently on bolus feeds of Peptamin Prebio
1.0, 410 ml q 3h x 5 daily, run over 1 hour as tolerated via NG tube. A modified Barium Swallow study
was ordered but will need to be rescheduled due to surgery for septic joints. Will evaluate diet
progression upon results of swallow study.

Nutrition related labs: Vit D and zinc levels are WNL. Pt is currently receiving supplemental zinc, Vit
D, and a MVI/mineral supplement. As serum Vit D and zinc levels are now WNL, recommend discharging
supplemental Vit D and zinc. Continue MVI/mineral supplement
 Resources
1. Mehta N, Corkins M, Lyman B et al. Defining Pediatric Malnutrition: A Paradigm Shift
Toward Etiology-Related Definitions. Journal of Parenteral and Enteral Nutrition.
2013;37(4):460-481. doi:10.1177/0148607113479972

2. PediTools Home. Peditoolsorg. 2016. Available at: http://peditools.org.

3. Pronsky ZCrowe J. Food Medication Interactions. Birchrunville, Penn.: Food-Medication

Interactions; 2015.

4. Tsze DValente J. Pediatric Stroke: A Review. Emergency Medicine International.

2011;2011:1-10. doi:10.1155/2011/734506.

5. Story M. Stang J. Nutrition And The Pregnant Adolescent. Minneapolis, MN: Center for
Leadership, Education, and Training in Maternal and Child Nutrition, University of
Minnesota; 2000.

6. Neale J, Nettleton S, Pickering L, Fischer J. Eating patterns among heroin users: a

qualitative study with implications for nutritional interventions. Addiction.
2012;107(3):635-641. doi:10.1111/j.1360-0443.2011.03660.x.