Question

JW is an 8 year old boy, short in stature and overweight for his size (Tanita scale measurements could not be accurately assessed (about the size of a normal 5 year old in height, but at least 15 lbs overweight). He appears to be a friendly and relatively well-mannered little boy, although he also suffers with some emotional issues. He has a great family support system- very caring parents and an older sister. The doctors are aware of all his behavioral issues but the major concern is his “fatty liver”, which at age 8 is an alarming situation, especially since he’s obviously not consuming alcohol.

History:

Pregnancy was extremely difficult, with unexplained elevated liver enzymes early and throughout in pregnancy with mom. JW was delivered C-section at 37 weeks. There was a delayed clamping of the cord which resulted in polycythemia. He grunted the first 12 hours although saturation of O2 was good. There was a suspected infection so he was given IV antibiotics for 5 days. He was jaundice and received light therapy.

Operations:

Circumcision @ 1 year of age

Adenoidectomy @ 3 years

JW suffered from ear infections as a toddler. He has been diagnosed with Asperger’s, Sensory Integration Disorder, low muscle tone, stunted growth, dyslexia, dysgraphia, ADHD and fatty liver.

Current difficulties:

JW is having a hard time emotionally. There are anxiety, anger and depressive periods. He has significant issues falling asleep, but once asleep he stays asleep. He’s always hungry, frequently thirsty, experiences numb and prickly sensations in hands and feet. In addition, there are GI issues including some bloating and stomach pain. He took himself off milk and ice cream at age 3 (yes you read that correctly), said it hurt his tummy. However he still loves to eat cheese. JW has frequent headaches and muscle aches. He is constantly in motion, flipping off furniture, repositions and walks around.

Medication and Supplements:

None- the parents have been resisting any medication for their son

Laboratory Data:

(These tests were already done at the time of first visit – requested by other physicians)

RBC- 5.0 x 106 /µL (N) (4.4-5.5)

WBC – 5.8 x 103/ mL (N) (4.5 – 10)

Neutrophils- 42% (L) (45-70%)

Lymphocytes- 47% (H) (28-48%)

Triglycerides – 217 mg/dL (H) (less than 90)

Total Cholesterol- 205 mg/dL (H) (less than 170)

LDL – 138 mg/dL (H) (less than 110)

HDL – 28 mg/dL (L) (> 39)

ALT – 89 U/L (H) (7 – 45)

AST – 65 U/L (H) (7-45)

ALP – 447 U/L (H) (169 – 401)

Additional lab tests were done to help identify the best nutritional support for JW.

Genova IgG - Bloodspot:

Mild reactions for: Eggs, Wheat, Asparagus, Gluten, also tested positive for Candida albicans in a prior test (mother not sure if it was stool or some organic acids)

Genova Metabolic Analysis (Urine):

Indications of low: Thiamin, Riboflavin, Pyridoxine

Other:

Fasting blood glucose- 97 mg/dL (HN) (70-99)

B12 Serum pg/mL – 176 (L) (211 – 296)

Glutathione (GSH) – 147micromol/L (L) (225 – 386)

Vitamin. D 25 OH – 27 ng/mL (L) (30 – 100)

RBC Zinc- 6.9 mcg/g (L) (7.8-13.1)

Vitamin A Serum (retinol) 17 µg/dL (L) (18 – 77)

Ferritin 23 ng/mL (LN) (16 – 77)

TSH 3.8 mU/L (HN) (0.465 – 4.68)

TPO AB – Negative

Questions

Discuss how this additional data relates to JW’s history and present clinical presentation.

Offer 3-5 specific dietary revisions for JW. Discuss your rationale for each and support with literature evidence where appropriate.

Based on JW’s clinical and laboratory data, suggest at least 3 supplements (you may suggest more if indicated) that address the concerns indicated. Discuss your rationale for each and support with literature evidence where appropriate.

Answer 1

1) The Present clinical condition of JW is directly influenced by the prenatal history.

• Firstly, as mentioned in the case that during pregnancy her mothe's liver enzymes were elevated which is A MAJOR RISK FCTOR FOR PRE ECCLAMPSIA.
• Secondly, It was a c-section and not a normal delivery Which makes it more prone for complications.
• Third and Major concern is delayed cord clamping at the time of birth resulted in polycythemia which leads to hyperbilirubinemia in child as evidenced by increased  ALT – 89 U/L (H) , AST – 65 U/L (H) and ALP – 447 U/L (H) levels.
• Fourth problem is presence of grunting during first 12 hrs which is clear sign of RESPIRATORY DISTRESS which is again a risk factor for ADHD.

2)

a) Low cholestrol diet or low fat diet is prescribed as test result shows high level of bloood cholestrol

(Triglycerides – 217 mg/dL (H), Total Cholesterol- 205 mg/dL (H).

b) High Protein diet except milk and eggs. (As JW is intolerant to them)

c)Increased water intake - it ill help in eliminting toxins produced in body

d) Avoid foods and drinks that contain large amounts of simple sugars, especially fructose. Fructose is found in sweetened soft drinks, sports drinks, sweetened tea, and juices.

Things to include:

• Fish
• Fruits
• Grains EXCEPT WHEAT
• Nuts
• Olive oil
• Vegetables

References

Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55(6):2005

3)

a) Vit A supplement to be taken (Vitamin A Serum (retinol) 17 µg/dL (L) )

Foods that are particularly high in vitamin A include:

• carrots.
• sweet potatoes.
• winter squash.
• cantaloupe.
• apricots.
• spinach, kale, and collard greens.

b)Vit D and Calcium suppliment

c) Vit B12 Supplement Eg

• Animal Liver and Kidneys. Organ meats are some of the most nutritious foods out there. ...
• Clams. Clams are small, chewy shellfish that are packed with nutrients. ...
• Sardines. Sardines are small, soft-boned saltwater fish. ...
• Beef. Beef is an excellent source of vitamin B12. ...
• Fortified Cereal. ...
• Tuna. ..