NICU/Peds Case Study

NICU/Peds Case StudyChristine Malia Cabral and Yasuko KatoLearning ObjectivesIdentify nutritional concerns in infants with cleft palate.Utilize growth charts for nutritional assessment of a peds pt.Calculate calorie/protein requirements to support catch-up weight gain.

Learning Objectives (cont)Calculate calories and protein provided by an infant formula recipe.Describe nutritional interventions for a peds pt with a FTT diagnoses.Identify community resources available for peds patients and their families. Baby Girl K8mo girl; born 9/28/2013 at 39 3/7 (term)Measurements at birthWt: 2.84 kg (AGA) Length: 46.7 cm (SGA)Head Circumference: 34.4 cm (AGA)

WHO weight-for-age

WHO length-for-age

WHO head circumference

WHO weight-for-length

DiagnosesPierre Robin SequenceBilateral cleft palateDysphagia, aspirationGERD

NICU Clinical Course27-day stayG-Tube placed 10/18/13Discharge Feeding Plan: Similac Advance, 4 bolus feedings during the day (60 ml @ 0900, 1200, 1500, 1800) and an overnight continuous feeding @ 30 ml/hr from 2000-0600.

Pierre Robin SequenceCongenital condition of facial anomaliesMicrognathia: Smaller than normal lower jaw Glossoptosis: Downward displacement/retraction of tongue, may obstruct airwayMost have a Cleft Palate

Complications:Breathing problems, Ear infections, and Reduced hearing, feeding problems

http://www.faces-cranio.org/Disord/PierreRobin.htm11Cleft palateThe roof of the mouth does not join together completely during pregnancySurgical repair often occurs between 9 18 monthsComplications:Ear infections, Hearing impairment, Speech problems, Dental problems, and Feeding difficulties

http://www.mayoclinic.org/diseases-conditions/cleft-palate/basics/complications/con-200246192) cleft of hard and soft palate, 3) cleft of soft palate12Nutritional ImplicationsDifficulty creating the necessary suction to pull milk from the bottle or breast.Increased feeding duration.Possibility for nasal regurgitation (milk coming out of the infants nose during a feeding)Missing/extra/malformed/displaced teeth and cavities Poor growth and weight gain

Social HistoryEthnicity: Hawaiian, Chinese, Japanese, Portuguese, American Indian, German19 y/o mother, not marriedNo siblingsLives with mother & father, paternal grandparents, and paternal aunt.Parents do not have their own means of transportationParents are both unemployed

Added the last bullet14Feeding Plan Changes (outpatient)10/28/13 Changed 20cal 24cald/t suboptimal weight gain11/18/13 Changed Similac Advance Similac Total Comfortwhey proteingastric emptyingreflux

Outpatient RD note 4/21/14

Outpatient CourseNo show for nutrition re-assessment appointment on 4/24.Peds RD made multiple attempts to contact parents with no response/call back.Weights: 04/09/14 4.905 kg04/21/14 4.763 kgPediatrician left message on 4/26 requesting weight check within 1 week, admit for FTT if insufficient weight gain.Weight check on 4/29, pediatrician recommended direct admission for FTT. Admit to MOA 4/29 Admission Dx: Failure to ThriveAdmission weight: 4.82 kgAdmission length: 59 cmDiet Order: 95 ml of Similac Total Comfort 24 cal/oz formula, 7 x/d, over 45 min.Feeds are at 600, 900, 1200, 1500, 1800, 2100 and 2400

100% whey, partially hydrolyzed proteinsSuitable for infants with lactose sensitivityContains prebiotics to help promote digestive healthAvailable on WIC program

Interview with parentsParents admit to staying up late (until 3 or 4 am) and missing 6 am feeding. Unable to recall correct recipe and feeding plan.Requested adjusted feeding planwant continuous feed overnight in addition to bolus feedings during the day. Dont want 6 am feeding.Baby K is on the WIC program (later conversation w/ WIC RD reveals parents have not received formula from them since late 2013).Weight-for-ageWHO Girls 0-2 years

Length-for-ageWHO Girls 0-2 years

Head Circumference-for-ageWHO Girls 0-2 Years

Weight-for-lengthWHO Girls 0-2 years

Interpretation of Growth ChartsWeight loss of 80g over the past 3 weeks (4/9-4/29)Any weight loss for peds patient is not good Length age of 3 months and weight age of 2 monthsWt-for-age