Running Head: MNT CASE STUDY- PEDIATRIC T1DM 1

MNT Case Study: Pediatric Type I DM, Patient Pseudonym: RR

Alexis Hammer and Olivia Zarrelli
Marywood University
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Introduction

In 2011-2012, the annual incidence of diagnosed Diabetes in youth was estimated at

17,900 with Type I Diabetes, and 5,300 with Type II Diabetes (Chiang 2014). Seven years

from now, it can be assumed that the prevalence of this disease will grow to affect children at a

younger age than the present diagnosis age of adolescences. Type I Diabetes accounts for 5%

to 10 % of all diagnosed cases of diabetes (Nelms 2011). This form of diabetes develops more

frequently in children and adolescents (Nelms 2011). Throughout this case study we will

investigate a situation involving pediatric Type I Diabetes Mellitus. The patient will be

referred to by the pseudonym RR throughout the remainder of this paper.

Patient Description

The patient RR is a twelve-year-old female, currently in the seventh grade. She stays

active by playing soccer and participating in PE class throughout her school day. She is of

Caucasian descent and speaks English as her only language. She identifies her religion as

Catholic. Her family consists of a split (divorced) situation between the mother and father. The

father resides in the city and the mother did not identify a location of residence. The patient has

a brother, age 4, and a sister, age 8. RR appears slim and generally healthy at five feet tall and

weight (at time of admission) was 82 pounds. She falls in the 50th percentile for stature for age

(National Center for Health Statistics 2016). RR falls in the 25th percentile for weight for age

(National Center for Health Statistics 2016). The ideal body weight for the patient is 100 lbs.

She is at the 82nd percentile for meeting this goal. During assessment, RR stated that her clothes
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have been feeling loose and that her usual body weight is around 90 pounds. She is at the 91st

percentile for meeting this goal with a BMI of 16.

RR was on no regular medication prior to admission. It was stated that she suffered from

a recent case of strep throat, but it was not stated if she received any medications to treat

it. Although RR has no past medical history, her mother suffers from hyperthyroidism and her

father has hypertension. Her sister suffers from celiac disease. The patients mother and father

describe RRs diet history as picky. They state that she eats only chicken and fish for protein

sources. Salad, broccoli, carrots, tomatoes, and asparagus make up the patients main vegetable

sources. For breakfast she usually has cereal and milk or a Pop-Tart and milk. RR typically

packs her lunch for school. Her meals choices consist of a peanut butter and jelly or turkey and

cheese sandwich, both meals with chips, carrots and water. For dinner she usually has a salad, a

source of meat, pasta, potato, or rice. Dinner is usually prepared by her mom, when with her dad

she usually consumes foods such as pizza, Chinese takeout, cereal, ice cream, yogurt, fruits,

popcorn, chips or cookies. The patient states that she has been feeling more hungry than

usual. RR also stated that she has been more thirsty than ever, and due to her increased thirst,

she has been waking during the night to urinate frequently.

Disease Information

The patient suffers from Type 1 Diabetes Mellitus which is an immune mediated,

autoimmune destruction of beta cells in the pancreas, therefore the pancreas can no longer

produce insulin (Nelms, 2011). Glucose cannot enter cells, causing plasma glucose levels to rise

(hyperglycemia) and cells to starve. Pathophysiology of Type 1 DM includes polydipsia

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(excessive thirst), polyphagia (excessive hunger), glycosuria (glucose in the urine due to bodys

need to eliminate excess glucose from bloodstream), increased risk for depletion of protein stores

as a result of elevated risk of diabetic ketoacidosis.

A recent research study was completed investigating the incidence of diabetic

ketoacidosis (DKA) in children with newly diagnosed Type 1 Diabetes. The research article

completed a retrospective analysis of 224 children with newly diagnosed Type 1 Diabetes and

the most common symptoms in these 224 children with Type 1 Diabetes were polydipsia,

polyuria, and weight loss (Chen, 2017). This study concluded that DKA has a high incidence

rate in children with Type 1 Diabetes.

After having fainted at soccer practice after only 15 minutes of exercise, RR was taken to

the emergency room. Her admitting signs and symptoms in addition to fainting include extreme

thirst, increased urination, increased hunger, and unintentional weight loss. These are all

symptoms which support the study discussed above, putting RR at risk for developing diabetic

ketoacidosis. She was admitted as having acute-onset hyperglycemia. As stated in the article,

Type 1 Diabetes Through the LifeSpan: A Position Statement of the American Diabetes

Association, assessing the history of acute complications (e.g., severe

hypoglycemia/hyperglycemia and diabetic ketoacidosis [DKA]) is important, RR and her

guardians should monitor not only her blood glucose levels, but also acute complications such as

her hyperglycemia to report back during follow-up sessions with the doctor (Chiang, 2014).

After an emergency room assessment was completed, it was found that RR had a serum

glucose of 724 mg/dL. The average serum blood glucose (taken at a random time) will be less
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than 125 mg/dL (6.9 mmol/L)(Hurd, 2017). This shows how elevated the patients serum blood

glucose was when she entered the ER. Diagnostic tests completed on RR include vital signs

(temp- 98.6, BP: 122/77, Pulse: 101, Resp. Rate: 22), lab tests (BMP stat, Phos stat, Calcium

stat, UA with culture if indicated Stat Clean catch, Bedside glucose Stat, Islet cell autoantibodies

screen, Thyroid peroxidase abs, TSH, Comp Metabolic Panel (CMP), Thyroid peroxidase abs, C-

peptide, Immunoglobulin Antibodies, Hemoglobin A1c, Tissue transglutaminase), nursing

assessment. While admitted in the hospital, RR was NPO except for ice chips and

medications. After 12 hours clear liquids she was stable enough to advance to a constant CHO

diet order of 70-80 grams for breakfast and lunch, 85-95 g, dinner; 3-15 grams snacks.

Type I Diabetes does not impair nutritional status if a healthy diet is followed, but

individuals with Type 1 diabetes mellitus (T1DM) are at increased risk of developing celiac

disease (Allison, 2014). In a research article discussing nutritional status, growth and disease

management in children with single and dual diagnosis of Type 1 Diabetes Mellitus and celiac

disease, it was found that individuals with Type 1 Diabetes Mellitus (T1DM) are at increased

risk of developing CD (Allison, 2014). The article also states that genetic predisposition, young

age at T1DM onset, female gender and early introduction of gluten in the infants diet have been

associated with an increased risk of development of CD in people with T1DM (Allison,

2014). With that said, RR can theoretically be at risk of CD due to the increased risks caused by

Type 1 Diabetes and genetics. Those who suffer from Type I Diabetes must follow a consistent

carbohydrate diet in order to maintain blood glucose levels throughout the day. A healthy

balanced diet is the key for individuals with Type I Diabetes. As stated in the journal article by

the American Diabetes Association, Type I Diabetes care must be an iterative process, adapted
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as the needs of the individual evolve (Chiang, 2014). As learned in class, a patient, such as RR,

suffering from Type I DM needs a diet that is individualized to meet her needs.

Laboratory Findings

Relevant lab data in regard to RRs new diagnosis of Type I Diabetes Mellitus includes

sodium, glucose, phosphate, osmolality, HbA1C, C-peptide, WBC, and urine pH, protein,

glucose and ketones in the urine. Being that RRs sodium is low, her potassium is high due to the

inverse relationship between sodium and potassium. It has been found that there is an inverse

relationship between serum sodium (Na) and potassium (K) levels in patients with diabetic coma

(Hayashi, 1999). Sodium and Potassium levels are dependent upon plasma glucose levels in

many diabetic patients. There may be some association between T1DM and the movement of

electrolytes between intra- and extracellular spaces, dependent on the impaired insulin action as

well as hyperosmolarity (Hayashi, 1999).

RRs glucose levels were high due to the bodys inability to transport glucose via insulin

to the cells, resulting in hyperglycemia. She also had decreased C-peptide levels, which indicate

that she was not producing insulin. Similarly, osmolality was elevated because of the bodys

inability to mobilize the glucose. Her extremely high HbA1C level was due to hyperglycemia

that went uncontrolled and unnoticed for a period of months prior to her fainting incident and

admission to the hospital. Her high WBC count was likely a reflection of the bodys response to

inflammation as a result of hyperglycemia and general lack of homeostasis. Acidity of the urine,

proteinuria, glucosuria, and the presence of ketones in the urine are all associated with extreme
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hyperglycemia. According to Nelms, the first sign of of T1DM in children and adolescents can

be ketoacidosis(Nelms, 2011, p. 483). Considering the lab results and symptoms of slight

confusion mentioned in the case study, she was likely admitted with diabetic

ketoacidosis. Proteinuria is linked to loss of kidney function in Type I diabetics. In addition, the

elevated levels of protein in the urine was the result of gluconeogenesis. The body began to use

protein for energy because of cell starvation, which resulted in the production of ketones and

their presence in the urine.

Analysis of Dietary Intake

During the 24- hour dietary recall, the patient, RR, reported consuming breakfast around

7:30 am. Her breakfast included 2 Pop-Tarts, a banana, and 16 oz. of skim milk with two

tablespoons of Ovaltine. RR ate lunch around 12 noon, and her lunch consisted of 2 (8) slices

of pepperoni pizza, 2 medium sized chocolate chip cookies, and 8 oz. of water. For snack

around 2:00 p.m, RR consumed 1 granola bar (no brand/type was specified). Her second snack

of the day was consumed at 4:30 p.m before soccer practice. At this time, she ate an apple, 6

saltine crackers, and 2 Tbsp. peanut butter. During RRs hour and half soccer practice, she

reported consuming 1, 16 oz. Gatorade (flavor not specified). Following soccer practice, RR ate

dinner (chicken with broccoli stir fry) which contained 1 c. fried rice, 2 oz. chicken, c.

broccoli, 1 egg roll, 16oz. skim milk. Around 8:30 p.m, RR had a night-time snack of 2 c. ice

cream, 2 Tbsp. peanuts. Besides being physically active at soccer practice for an hour and half,

RR reported having thirty minutes of physical activity during physical education class.
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A major pro of RRs diet is that she actually consumed breakfast prior to her school

day. According to EatRight Pros article, Breakfast in Schools: Healthy & Nutritious, 42% to

59% of American children do not eat breakfast everyday (Breakfast in Schools: Healthy &

Nutritious, 2017). This is detrimental to children because research shows that shows that kids

who eat breakfast regularly tend to be more alert in school, and, therefore, are able to learn better

(Breakfast in Schools: Healthy & Nutritious, 2017). Therefore, RR consuming breakfast is a

pro of her diet. Another advantage of the patients diet is the amount of dairy she is consuming.

She is sufficiently meeting her RDAs for dairy by consuming skim milk at breakfast and dinner,

and ice cream as a snack following dinner. RR is also sufficiently meeting her protein needs.

One con of RRs diet is inadequate intake of vegetables. An appropriate goal for her

would be to increase her vegetable intake to at least 3 vegetables a day. Another con of her diet

includes the amount of processed foods. RR consumes Pop-Tarts, pepperoni pizza, cookies, ice

cream, etc. Reducing the consumption of these foods would result in better glycemic control,

and allow for room in the diet for foods that are nutrient dense and high in fiber. This would

assist in stabilizing the blood glucose level of the patient. Based on Super-Tracker, RR

consumed 3512 kcals, 459 grams of carbohydrates, 105 grams of protein, and 109 grams

fat. According to personal calculations that were completed, RR needs 1748 kcals/day, 35 grams

of protein/day, 130 grams carbohydrate/day, and 50-70 grams of fat/day. The Super-Tracker

program had the patient's target goals set as: 2200 kcals/day, 34 grams of protein/day, 130 grams

carbohydrate/day, and 48-68 grams of fat/day. *See appendix for Super-Tracker report of 24-hr.

dietary recall.
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From a registered dietitian standpoint, recommendations on a consistent carbohydrate

diet would be made. Nutrition education would have to be provided to the patient and her

guardian/caretaker informing of the most consistent method of consuming carbohydrates in order

to relieve the patients symptoms. It would also be suggested for RR to consume more fiber. A

healthy diet that includes soluble fiber can assist in slowing the absorption of sugar and help

improve blood sugar levels. A dietitian would also recommend caution of consumption of

products with high levels of added sugars.

Nutrition Care Process

The PES statements for RR are as follows:

1. Involuntary weight loss related to complication of Type 1 DM, as evidenced by loose

fitting clothing and 8-pound weight loss within several months.

2. Food and nutrition knowledge deficit, related to new diagnosis of Type I DM, as
evidenced by dietary recall.

3. Excessive urinary excretion, related to increased thirst (polydipsia), as evidenced by

frequent trips to restroom.

Goals for RR to manage her disease are stabilize glucose, maintain physical activity

level, improve knowledge of the diet necessary to control hyperglycemia, and gain knowledge of

how to use insulin with the appropriate dosages. Stabilizing glucose levels is a primary goal in

T1DM in order to prevent serious, life threatening complications of the disease such as diabetic

ketoacidosis. Incorporating methods of blood glucose control into ones lifestyle is crucial
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because poorly managed hyperglycemia can lead to retinopathy, nephropathy, and neuropathy in

the long term (Nelms, 2011).

Physical activity can aid in the management of T1DM in the areas of improved glycemic

control, improved blood lipids, reduced risk of CVD, improved stress management, and overall

better quality of life (Nelms, 2011). Being that RR enjoys playing soccer, another goal would be

to allow her to continue by working with her diabetes to ensure her blood sugar remains stable

while exercising. Adjustments in RRs insulin dosage and/or carbohydrate consumption before

exercise will have to be made. An extra dose of insulin or a snack containing 30 grams of

carbohydrates before her 1.5-hour soccer practice is necessary to prevent hypoglycemia (Nelms,

2011). RR and her family should be educated on the proper diet to control her diabetes, and

ways to incorporate nutritious foods that RR enjoys into her current diet. Increasing

consumptions of vegetables, particularly non-starchy vegetables is one-way RR could improve

her diet. Increasing her fruit and vegetable intake will ensure she gets more vitamins and

minerals as well as fiber, to help slow digestion and keep her blood glucose stable for

longer. RR will need to follow a carbohydrate consistent diet to keep her blood glucose

consistent to prevent any sudden spikes or dips.

Since being prescribed the type and doses of insulin by the physician, she and her family

will have to be given instruction on how to administer and the proper timings of when to

administer. According to Nelms, individuals using conventional therapy must synchronize

administration of their insulin and food intake to avoid hypoglycemia. A good understanding of

onset, peak, and duration of their insulin dose in relation to their meals and snacks in addition to
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consistency of food intake is also important(Nelms, 2011). This can be a new learning curve for

the family, especially in their split custody situation. A certified diabetes educator would be

beneficial to the family, especially due to the fact that this is the first case of diabetes within the

(nuclear) family medical history.

Conclusion

This case study showed that the patient suffered many symptoms related to lack of

endocrine function. Generally, the patient is physically active, participating in physical activities

in PE class (for a half hour) as well as long duration soccer practices, therefore this sudden

episode of fainting after only 15-minutes of exercise, lead medical professionals to assume that

she was suffering from a form of an acute-disease. Upon arrival in the emergency room, RR was

found to have extreme acute- onset hyperglycemia, decrease in c-peptide, proteinuria, acidity of

the urine, glycosuria, the presence of ketones in the urine, and slight mental confusion. After

further investigation and tests, it became apparent that these abnormal levels were caused by

diabetic ketoacidosis, which became the marker for her new diagnosis of Type 1 Diabetes

Mellitus.

If RR was not brought into the emergency room after the fainting episode, she could have

suffered from even more severe symptoms, such as diabetic coma or even death. Diabetes was

the seventh leading cause of death in the United States in 2015 based on the 79,535 death

certificates in which diabetes was listed as the underlying cause of death. In 2015, diabetes was

mentioned as a cause of death in a total of 252,806 certificates (Chiang, 2014). Due to the fact

that no one else in RRs family suffers from an endocrine disease such as T1DM, RR could have
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been suffering for some time with symptoms unrecognizable to herself or her parents. While

Type I Diabetes can be inherited genetically, lifestyle factors can also play a major role in the

development of the disease. Although there is no known cure, it is possible to live with Type I

Diabetes. Through insulin treatment, dietary cautions, and appropriate lifestyle adjustments,

individuals like RR can live a healthy life.

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Chen, Y. Q.,Sun, M. Y.,Tao, N., Wang, A. P., , Zhang, H. H. (2017, October). [An investigation
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Chiang, J. L., Kirkman, M. S., Laffel, L. M., & Peters, A. L. (2014). Type 1 Diabetes Through
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Hayashi, H., Higashiyama, M., Saito, T., Ishikawa, S., Nakamura, T., Rokkaku, K., . . . Saito, T.
(1999). Inverse Distribution of Serum Sodium and Potassium in Uncontrolled In Patients with
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Hurd, R. (2017, April 15). Medical Encyclopedia: MedlinePlus. Retrieved October 31, 2017,
from https://medlineplus.gov/encyclopedia.html

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Nelms, M. N., Sucher, K., & Roth, S. (2011). Nutrition Therapy and Pathophysiology(2nd ed.).
Boston, MA: Cengage learning.