Emma Jordan Specialist Paediatric Dietitian

Transcription

1 Emma Jordan Specialist Paediatric Dietitian

2 - Referred by school nurse age 11 years and 6 months - Presenting complaint: Low dietary intake, mainly vegetarian, low fat intake, getting increasing fussy with eating - Very underweight for height: - Weight: 21.3kg (<0.4 th centile) - Height: 135cm (9 th centile) - BMI: 11.7 >4SD below 0.4 th centile

3 Social: Lives with mum, grandma, 6 year old sister, and 15 year old brother. Father passed away when child was 6 years age. Received bereavement counselling. Attends mainstream school School Nurse advised cooking regularly at home with mum and adding extra fats to foods. Medications: Nil Medical history: Nil of note

4 Feeding history: Term Baby good weight, breast fed until 1.5 years, growth not an issue, eating well until 3 years age, food intake been decreasing gradually Mum concerned about possible eating disorder, extreme low weight, bone health and general dietary intake

5 Breakfast: dry cereal with water and fruit shoot Lunch: Dry jacket potato with cheese occasionally, water/juice Evening: Plain noodles and fruit shoot Crisps/chocolate occasionally Fruit 1-2/day Vegetables 3 /day

6 Blood tests requested for Vitamin D, iron and bone profile Increase vegetarian sources of protein eg eggs, beans etc Food fortification Fresh juice with cereal in the morning Milky drink in morning and evening Start Multi-vitamin and calcium Review 2 months

7 Subsequently seen by 3 different Dietitians every 2-3 months Little change in dietary intake, continues to be stubborn with food Tension between mother and daughter, mealtimes reported to be stressful Low iron levels Tried with various different ONS Repeated failed attempts to get input from CAMHs Remains very underweight

8 Age Weight - kg 11 yrs 6 mths 11 yrs 9 mths 11 yrs 11 mths 12 yrs 4 mths 12 yrs 6 mths Centile Heightcm Centile BMI 21.3 <0.4th 135 9th <0.4th <0.4th nd -9th <0.4th nd -9th <0.4th nd -9th 12.9

9 Try and see child and mother separately at next dietetic appointment Discuss impact of eating on whole family What is stopping the family from moving on? Are there any other behavioural issues? Ask about child s general wellbeing, eg sleep, mood, going out with friends, family holidays

10 Mother highlighted obsessive behaviour, unable to sleep alone, dislikes being hugged, few friends at school, always washing hands, cousin has autism. Doing very well academically, except in English. Anxiety major problem if routine not followed Child feels that she is sleeping OK, likes to eat the same foods every day. Holidays are OK as her auntie makes bagels with nutella.

11 9am White toast x 2 with nutella, 1 cup of apple juice and water 1pm Pasta with cheese/ jacket potato with butter/ home made chips and cheese/ 2 chapatti with 2 cups of apple juice and water 6pm plate full of quinnoa with chick peas/ 2 chappatis/ 1.5 bowls of rice with butter/ rice with chick peas, 1 fruit shoot 8pm quarter of a cucumber, bowl of grapes

12 Estimated intake from food diary: 2000 kcal/day and 50-60g/protein Estimated requirements: 2500 kcal /day (500kcal for weight gain) and 41.2g/ protein

13 Eat extra portions of familiar foods when hungry Protein at each meal eg cheese, nutella, chick peas, black eyed peas Bring cheese/chick peas from home to have on school jacket potato Continue with iron supplements GP to re-check iron levels Dietitian to make CAMHs referral Review in clinic 3-4 months

14 Age 12 years 10 months CAMHs referral accepted Age 13 years 2 months S/B CAMHs OT to be referred for neurodevelopmental assessment and group work Age 13 years 7 months S/B Dietitian in clinic to continue with previous plan

15 Age 13 years 11 months seen by Psychologist, being reviewed weekly due to low BMI, needs to get to 90% ideal body weight and then assess for ASD, aim 0.5kg week weight gain Age 14 years seen in dietetic clinic having weekly appointments with Psychologist and weekly group to discuss anxiety All physical activity and sports is banned Attends luncheon club in school Mum has to sit with child at every meal time Whole family very stressed

16 Liaise with Psychologist as to role of dietitian Continue to work on gradually increasing quantities of food Review in clinic 3-4 months

17 Community Psychology Nurse taken over from Psychologist Limiting Physical activity Support for lunchtime in school CAMHs anxiety group Encourage patient to eat foods that she feels comfortable with and increase quantities Continue to work on food quantities at next dietetic appointment Discuss future dietetic follow-up with patient and family

18 Age Weight - Kg 12 yrs 9mths Centile Heightcm Centile BMI 25.7 <0.4th th yrs 26.5 <0.4th 145 9th yrs 3mths 13 yrs 7mths *13 yrs 11mths <0.4th 146 9th <0.4th 148 9th <0.4th yrs 32 <0.4th 151 9th yrs 2mths * CAMHS th - - -

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20 Multi-disciplinary approach essential S/B Paediatrician as a one-off no concerns highlighted Low BMI repeatedly flagged up and ignored until S/B Psychologist Extreme persistence needed to refer to CAMHs service, professional helpline invaluable Long CAMHs waiting lists originally quoted 1 year for family to wait for treatment

21 Good communication with CAMHs essential to ensure shared goals Lack of NHS resources How can a general paediatric dietitian best support these families? Sources of further support?