The Child with Endocrine Dysfunction

1
The Child with Endocrine Dysfunction

• Hockenberry Chapter 38
• ATI pg. 333-373, 408-429
• Dondi Kilpatrick RN, MSN

2
Learning Objectives

• List Signs and Symptoms
• Verbalize treatment plan for
• Diabetes Type I and II
• Hyperglycemia
• Hypoglycemia
• Growth Hormone Deficiency
• Growth Hormone Excess
• Diabetes Insipidus
• SIADH
• Hypothyroidism
• Hyperthyroidism

3
Disorders of Pancreatic Hormone Function

• Review
• Islets of Langerhans
• 3 major functioning cells
• Alpha cells
• Beta cells
• Delta cells
• Balance out the insulin and glucagon

4
Diabetes Mellitus (DM)

• Metabolic disorder
• Chronic hyperglycemia
• Total /partial deficiency of hormone INSULIN
• Impairs the bodys ability to use food for energy
• Most common chronic endocrine disorder of
  childhood
• No cure

5
Diabetic Ketoacidosis

• Insulin facilitates entry of glucose into cells
• Too little insulin ? body burns fat for energy
• Fat breaks down ? fatty acids
• Glycerol in fat ? ketones in the liver
• Excess is eliminated in urine (ketonuria) or
  lungs (acetone breath)
• Ketones in blood are strong acids lowering pH
  (ketoacidosis)

6
Stuff from bottom of slide

• Insulin facilitates entry of glucose/K into the
  cell.
• Too little insulin
• body in a state of starvation causing hunger
  (polyphagia)
• concentration of glucose increases in the
  blood stream
• when glucose exceeds the renal threshold,
  glycosuria occurs
• this in turn causes osmotic diversion of water
• (to dilute the glucose) causing polyuria
• increased diuresis causes excessive
  thirst(polydipsia)
• Body still needs energy, so it starts burning
  fat for energy.
• Fat breaks down into fatty acids and the glycerol
  in fat Is converted to ketones by the liver.
• Excess ketones are eliminated in the urine
  (ketonuria)
• Or by the lungs (causing acetone or fruity
  breath)Ketones are strong acids in the blood
  (ketoacidosis)

7
Ketoacidosis

• Ketones produce free hydrogen ions (? serum
  pH)
• Bicarbonate in blood combines with hydrogen ions
  to make carbonic acid (which breaks down to H2O
  CO2)
• Lungs try to eliminate CO2 by altering rate
  depth of respirations (Kussmaul

8
Stuff from bottom of slide

• Ketones also produce free hydrogen ions which
  decreases the serum pH
• To counter the decrease in pH, bicarbonate binds
  to the
• hydrogen ions in an attempt to buffer the pH.
  This binding produces carbonic acid, which breaks
  down into H2O
• and CO2
• To eliminate the CO2, the lungs alter the rate
  and depth of respirations (Kussmaul respirations
  hyperventilation associated with metabolic
  acidosis)

9
Ketoacidosis

• With cellular death
• Potassium ? released from cell ? blood stream
  (intra to extracellular) ? excreted by kidney
• Total body potassium is depleted, even though
  serum potassium may be elevated
• If not reversed ? dehydration, electrolyte
  imbalance, acidosis, coma, death

10
Ketoacidosis

• As the acidosis worsens, cellular death occurs.
• With cellular death, potassium is released from
  the cells
• to the bloodstream, and is excreted by the
  kidneys. The
• potassium loss is accelerated by the diuresis
  already taking place.
• Total body potassium is decreased, even though
  the serum
• potassium may be elevated (due to decreased fluid
  volume
• from the diuresis)
• K ? bloodstream ? kidney and increase loss by
  osmotic diuresis
• Total body potassium decreases even though serum
  potassium may be increased

11
Ketoacidosis

• Treatment
• Insulin
• Fluids
• Electrolytes (particularly potassium)
• Happens most frequently with infection
• From bottom of slide
• As insulin given K shifts into cells decreasing K
• K given post confirmation of renal fx
• Gradual reduction of BS

12
Diabetes Mellitus (DM)

• Type 1
• Beta cell destruction
• Leads to absolute insulin deficiency
• 5-10 of all DM cases

• Type 2
• Insulin resistance
• 90-95 of all DM cases
• Historically more common in adults gt 45
• ? prevalence seen in children/adolescents

13
Causes

• Type 1
• 2 types
• Auto immune
• Idiopathic
• Not simple inheritance
• Genetic predisposition plus trigger event

• Type 2
• Insulin resistance plus relative insulin
  deficiency

14
Risk factors for Type II

• Overweight
• Decreased exercise pattern
• Family history of type 2 DM
• Age
• Non-European ancestry

15
Signs and Symptoms

• Type 1
• Polyuria
• Polydipsia
• Polyphagia
• Rapid weight loss
• Dry skin
• Irritability
• Drowsiness/fatigue
• Abdominal discomfort
• Ketoacidosis

• Type 2
• Polyuria
• Polydipsia
• ? BP
• Frequent infections
• Fatigue
• S/S insulin resistance
• Acanthosis nigricans
• Polycystic ovary disease

16
Acanthosis nigricans
www.aocd.org/skin/dermatologic_diseases/acanthosis
Acanthosis nigricans screening program
17
Treatment
Team approach!!!

• Type 1
• Insulin!
• Monitor glucose levels
• Lifestyle changes
• Nutrition
• Exercise

• Type 2
• Lifestyle changes
• Nutrition
• Exercise
• Oral meds
• Monitor glucose levels

18
Insulin

• Types
• Human
• Most of what we see
• Pork
• Not used much at all
• All types
• 100 units/ml

19
Types of Insulin

• Based on
• Onset
• Peak
• Duration

• 5 types
• Rapid
• Short
• Intermediate
• Long
• Mixed

20
Types of Insulin

• Rapid
• Give within 15 minutes of a meal!!!
• Intermediate
• Is cloudy
• Long acting
• Lantus cant be mixed in a syringe with any other
  insulin

21
Insulin Mixtures

• 70/30 50/50 75/25
• 1st - of intermediate insulin
• 2nd - of short or rapid acting insulin
• Pay attention to the name of the mix!!!!
• 70/30 is 70 NPH and 30 short acting

22
Mixing Insulin

• Administer mixed insulin within 5 minutes of
  mixing or wait 15 minutes
• Ignore this slide, she wont test us on it

23
Insulin Dosing

• One dose a day rarely suffices
• Split mix is common
• Rapid/short acting mixed with NPH
• Given prior to breakfast and supper
• For better control- multiple injections

24
Insulin Administration

• Subcutaneous administration
• Rotate sites
• Insulin absorption
• Abd is fastest, arm is next, and the leg is the
  slowest

www.rch.org.au/diabetesmanual/manual.cfm?doc_id27
33injection_sites
25
Insulin Administration

• Complications
• Lipoatrophy
• Where the tissue atrophies or breaks down, little
  pitting areas
• Lipohypertrophy
• Build up of fat, like a fatty nodule

26
Insulin Administration

• Insulin pen
• Resembles a large fountain pen
• Needle is screwed onto tip immediately prior to
  injection

27
Insulin Administration

• Insulin pump
• Computerized device
• About the size of a pager
• Worn around the waist
• As close to normal insulin delivery as possible
  now
• Drawbacks
• Pump malfunction, cant get air in line, have to
  know how to do calculations and work the device

28
Insulin Administration

• Absorption can be altered
• exercise
• illness
• Self monitoring is a must!!!
• This disease is lifelong so when the kid gets old
  enough to do the shit himself, he needs to do the
  shit himself

29
Oral Medications

• Type 2 DM children only
• Used if lifestyle changes are not effective
• Decreases absorption of blood sugar from the
  diet, reduces the insulin usage.

30
Monitoring

• Self- blood glucose monitoring
• At home in hospital
• Goal- blood glucose 80-120 mg/dl
• Glycosylated hemoglobin (Hgb A1c)
• Typically levels of 6.5-8 are acceptable
• Blood sugar attaches to the hemoglobin for the
  life of the hemoglobin, the hemo lives about 120
  days
• A level of 6 means your avg blood sugar is about
  120
• Every number increase is about an increase of 30.
  So 7 is about 150

31
Monitoring

• Finger sticks / Atraumatic care
• Warm the finger
• Use the ring finger and thumb
• They bleed a little bit easier
• Puncture to the side of the finger pad

32
Complications

• Hyperglycemia
• Caused by
• Too little insulin
• Illness/infection
• Injury
• Stress- physical/emotional
• Decreased exercise
• Diet

33
Hyperglycemia

• Symptoms
• 3 Ps
• Nausea
• Blurred vision
• Fatigue
• Diabetic ketoacidosis (DKA)

• Treatment
• Drink extra fluids
• Administer additional insulin
• Monitor glucose more closely

34
Complications- Hypoglycemia

• Caused by
• Too much insulin
• Diet
• Exercise
• Growth spurts
• Puberty
• Illness/injury
• Menses

35
Hypoglycemia
Symptoms

• Severe
• Inability to swallow
• Seizure/convulsion
• Unconsciousness

• Mild-moderate
• Shaky/sweaty
• Hungry
• Pale
• Headache
• Confusion
• Disorientation
• Lethargy
• Change in behavior

36
Hypoglycemia

• Treatment
• Often difficult to differentiate HYPO from
  HYPERglycemia
• Check blood sugar if possible
• When in doubt, give simple carbohydrate
• Follow with complex carbohydrate, then protein

37
Hypoglycemia

• If unconscious, seizes or cannot swallow
• Glucagon
• Mixed and given IM/SQ
• Releases stored glycogen from liver
• Should increase blood glucose in 15 minutes
• Can cause nausea/vomiting
• Protect from aspiration

38
Somogyi Effect

• Hypoglycemia followed by rebound hyperglycemia
• More common for type I, especially in children
• Signs and symptoms
• Treatment reduce bedtime insulin to prevent
  early a.m. hypoglycemia

39
Long Term Complications

• Vascular changes
• Involve large and small vessels
• Heart disease
• Retinopathy
• Neuropathy
• Arterial obstruction
• Gangrene

40
Education

• Always carry
• Glucose tablets
• Insta-glucose
• Sugar cubes
• Candy
• children may fake a reaction to get candy

• Exercise
• With good control
• Decreases insulin requirements
• With poor control
• May stimulate ketoacidosis

41
Education

• Nutrition
• Sufficient calories to balance daily expenditure
  for energy and growth
• Constant carbohydrate diet-exchange system
• Consistent intake/timing of food
• Timing of food coincides with time/action of
  insulin
• Total of calories/proportions of basic
  nutrients needs to be consistent day to day

42
Type I Diabetes

• Allow toddler and preschooler to make food
  choices - monitor Carbohydrates
• Monitor temper tantrums as possible signs of
  hypoglycemia
• Snacks should be available during increased
  activity such as sports activities

43

• Estimating Portion Sizes
• for eyeballing portion size
• 1 ounce of cheese is as big as 4 dice
• ½ cup of rice is as big as half a baseball
• A 4-ounce bagel is the size of a hockey puck
• 3 ounces of meat is as big as a deck of cards
• 2 tablespoons of peanut butter is about a
  Ping-Pong ball
• 1 cup of pasta equals a tennis ball

www.lillydiabetes.com
44
Education

• Illness management
• Monitor glucose every 3 hours
• Monitor urine ketones every 3 hours or when
  glucose is gt 240 mg/dl
• Urine ketones are not used for daily management

45
Disorders of Pituitary Function

• Pituitary gland
• Master gland
• Regulates other endocrine functions
• Releases or withholds 7 other hormones
• Growth hormone (GH)

46
Hypopituitarism

• Caused by
• Organic lesions (tumors)
• Idiopathic
• Usually r/t GH deficiency

47
GH deficiency

• Manifestations
• Short stature usually below 5th percentile
• Usually grow normally 1st year
• During the 2nd year growth drops off established
  percentile
• Height may be more retarded than weight
• Normal skeletal proportions
• Sexual development usually delayed, but normal
• Most have normal intelligence

48
GH deficency

• Diagnosis
• Physical exam
• Family history
• X rays
• Endocrine studies
• Growth chart

49
GH deficiency

• Treatment
• Correct underlying disease process
• Replacement of GH (80-90 successful)
• Biosynthetic GH drug of choice
• FDA approved for
• GH deficiency
• Chronic renal insufficiency
• Prader-Willi syndrome
• Turner syndrome

50
Growth Hormone Excess

• Hyperpituitarism
• Over secretion occurs prior to epiphyseal plate
  closure
• Grow 7-8 feet tall
• Acromegaly
• Over secretion occurs after epiphyseal plate
  closure
• Overgrowth of head, lips, nose, tongue, jaw,
  separation malocclusion of teeth, increased
  facial hair

51
Growth hormone excess

• Treatment
• Remove tumor, pituitary gland radiation, high
  dose sex steroids to close growth plates

52
Diabetes Insipidus (DI)

• Disorder of the posterior pituitary
• Results from HYPOsecretion of Antidiuretic
  Hormone (ADH)
• ADH sometimes called vasopressin (Pitressin)
• Produces uncontrolled diuresis
• Causes
• Primary familial or idiopathic
• Secondary trauma, tumors, CNS infection, aneurysm

53
Diabetes Insipidus (DI)

• Manifestations
• Cardinal signs POLYURIA POLYDIPSIA
• 1st sign is often ENURESIS
• Infants
• irritability relieved with feeding of WATER not
  milk
• dehydration often occurs

54
Diabetes Insipidus (DI)

• Management
• Instruct parents there is a difference between DI
  and DM
• Daily hormone replacement of vasopressin
• Drug of choice DDAVP
• Nasal spray or IV
• Treat for lifetime

55
Syndrome of Inappropriate Antidiuretic Hormone
(SIADH)

• Disorder of posterior pituitary
• Produces HYPERsecretion of ADH
• ADH causes reabsoption of water back into central
  circulation
• Causes
• Infection
• Tumors
• Trauma
• CNS disease

56
SIADH

• Manifestations
• Fluid retention but no edema
• HYPOtonicity
• Anorexia
• Nausea/vomiting
• Irritability
• Personality changes

57
SIADH

• Treatment
• Fluid restriction
• ¼-½ of maintenance
• We dont want further dilution in their body
• Correction of underlying disorder (infection,
  tumor resection, etc.)
• They may receive some diuretics, make sure to
  tell the families to get rid of other sources of
  water (toilet, plants, dog bowls)

58
Disorders of Thyroid function

• Hypothyroidism (juvenile)
• One of the most common endocrine disorders of
  childhood
• Congenital
• Congenital hypoplastic thyroid
• Acquired
• Partial/complete thyroidectomy for CA or
  thyotoxicosis
• Following radiation treatment for malignancy

59
Hypothyroidism (juvenile)

• Manifestations
• Decelerated growth
• Myedematous skin changes
• Dry skin, periorbital edema, dry or sparse hair
• Constipation
• Sleepiness
• Mental decline

60
Hypothyroidism (juvenile)

• Treatment
• Oral thyroid hormone replacement
• Treat promptly in infants to facilitate brain
  growth
• Lifelong treatment

61
Hyperthyroidism (Graves Disease)

• Most common cause of HYPERthyroidism in children
• ?? Caused by serum thyroid stimulating
  immunoglobulin, but no specific etiology
• Peak incidence 12-14 years, but can present at
  birth
• Familial association
• Diagnosis ? T4 and T3, suppressed TSH

62
Hyperthyroidism (Graves Disease)

• Manifestations
• Gradually develop over 6-12 months
• Excessive motion
• Gradual weight loss
• Muscle weakness
• Vomiting/frequent stooling
• Heat intolerance
• Skin-warm, moist, flushed

63
Hyperthyroidism (Graves Disease)

• Treatment
• Goal to retard rate of hormone secretion
• When S/S noted activity should be limited to
  classwork only
• Some controversy as to which treatment is best
• Antithyroid drugs (PTU and methimazole)
• Risk for agranulocytosis, have family watch for
  s/s of infection (sore throat and fever). Seek
  medical attention immediately
• Subtotal thyroidectomy
• Ablation with radioiodine

64
References

• DM
• www.diabetes.org
• http//diabetes.niddk.nih.gov/dm/pubs/type1and2
• www.emedicine.com/ped/TOPIC581.HTM
• Thyroid
• www.cushings-help.com/thyroid.htm
• www.healthsystem.virginia.edu/uvahealth/peds_diabe
  tes/hypothd.cfm