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Endocrine Stressors
and Adaptation
Common Pediatric
Endocrine Disorders
 Type I Diabetes
Congenital Hypothyroidism
Acquired Hypothyroidism (Hashimoto’s
Disease)
Hyperthyroidism (Graves disease)
Growth Hormone Deficiency
The Endocrine System
GlandsHormonesEndocrine disorders
Hypofunction
Hyperfunction
Primary
Secondary
Pediatric Differences in the
Endocrine System
The endocrine system is less
developed at birth than any other body
system
Hormonal control of many body
functions is lacking until 12-18 months
of age
Infants might manifest imbalances in
concentration of fluids, electrolytes,
amino acids, glucose, and trace
substances
Type I Diabetes
Most common endocrine
disorder in children
Pancreas becomes unable to
produce and secrete insulin
Peak age: 5-7, or at puberty
Abrupt onset
Genetic link
Type 1 Diabetes
Beta cells- type of cell found in the Islets of
Langerhans within the pancreas that make
and release insulin.
Insulin is a hormone required to move the
glucose into cells throughout the body.
If no insulin can be produced, the glucose
stays in the blood instead, where it can
cause serious damage to all the organ
systems of the body.
Etiology
Autoimmune
process causes
destruction on
insulin-secreting
cells in the
pancreas
At dx 90% of beta
cells are
destroyed
Type 1 Diabetes
No cure, but JDRF is funding
studies that perfect pancreas
transplantation and regeneration
the body’s own beta cells without
islet transplantation
Serum Glucose
Levels
Normal:
70-110mg/dl
Glycosated Hemoglobin Hgb A1C
1.8 to 4.0 is normal
> 6.0 = DM
Diagnosis:
fasting: >126mg/dl
Random (non-fasting): ≥ 200mg/dl
with classic signs (next slide)
Signs & Symptoms
Polyuria
Polydipsia
Polyphagia
Fatigue
Blurred vision
Headache
Shortened
attention span
Mood changes
Diabetic
Ketoacidosis(DKA)
Medical Emergency
As glucose levels rise, child will
progress into DKA if not treated
Blood glucose levels > 300
Cellular starvation leads to ketone production
Nausea, vomiting, abdominal pain
Acetone (fruity) breath odor
Dehydration
Kussmaul respirations
Coma if untreated
Juvenile Diabetes
Treatment
Multidiscipline
Goal: Normal G & D, optimal glucose
control, minimal complications,
adjustment to disease
Treatment consists of:
Insulin replacement
Diet
BG monitoring
Exercise
Diet Therapy
well-balanced, enough
caloric intake to support
growth and development
three meals, snacks spaced
throughout the day
no diet foods
don’t omit meals
Diet Therapy
No foods excluded,
encourage good nutritional
choices
learn dietary allowances
outside of home
need to have consistent
intake & timing of food to
correspond to the time &
effect of insulin prescribed
Exercise
Encouraged, never
restricted
Lowers blood glucose
levels, by aiding the body’s
use of food
Decreases insulin
requirements
Proper snack before Add an
extra 15- to 30-g carbohydrate snack for each
45-60 minutes of exercise
BG Monitoring
Glucose monitoring
Urine testing for ketones
Record keeping
Self-management at age appropriate
level
2-6 choose food, clean finger for BG
4-6 dip own urine
6-8 BGM
8-10 insulin injections, diary
10-14 nutritional decisions
12-18 full management
Insulin
Precise dose cannot be predicted
Amount is based upon average
capillary or serum blood glucose
levels
Will change based of G & D
Can be administered TID SQ by
needle/syringe, pen or by
insulin/portable pump
Types of Insulin
Synthetic Human Insulin
 Rapid acting
 Lispro (Humalog)
 Aspart (Novolog)
 Fast acting
 Regular ®
 Intermediate
 NPH (N)
 Mixed (70/30)
 Long Acting
 Glargine (Lantus)
 Ultra Lente
Typical Management
The peak of the insulin should
occur Post-Prandial (after meal) to
avoid hypoglycemia
Insulin
Alternate sites
Don’t inject
extremity to be
used in sports
Give at room
temperature
Always draw
regular up first if
mixing
Many are using
insulin pens
Pumps
 Delivers fixed amounts
of short-acting insulin
continuously
 Worn on a belt, the
tubing & catheter are
changed Q48 hours and
taped in place
 Should not be removed
for > 1-2 hours
 Subject to minimal
malfunction
 Self-motivated
Pumps
Advantages
Less scar tissue
No daily injections
Less to carry
Private
Sense of control
Disadvantages
Must wear continuously
Need to carry extra battery
Good BGM
If insurance dose not cover
$$$$$
Still need emergency
needles, insulin, and
remember how to inject
ILLNESS
alters diabetic management
Dosage requirements may increase,
decrease, or remain unchanged
depending on the severity of the illness &
the child’s appetite
Short-acting insulin used to manage
hyperglycemia associated with illness
Monitor fluids, may require extra oral
fluids while ill
Hyperglycemia BG > 160
Gradual onset
Lethargic
Polyuria
Polydypsia
Dulled sensorium, confused
Weakness, fatigue, lethargy
 Glucose 250 mg/dl
 Large ketones in blood & urine
 Blurred vision
 Ketoacidosis
 Coma
Hypoglycemia
BG < 70
Commonly occurs before
meals
when the insulin effect is
peaking
 burst of physical activity
without additional food,
delayed, omitted, or
incompletely consumed means
of snacks
Too much insulin-wrong dose
Signs & Symptoms
of Hypoglycemia
Rapid onset
Irritable, nervousness
Difficulty concentrating
Shaky feeling, tremors, hunger
Diplopia
Pallor
Weakness
Headache, dizziness
Sweating
Unconsciousness and convulsions
Treatment of
Hypoglycemia
Simple concentrated sugar
Glucose gel or SL tablets
Hard candy
Sugar cubes
Low-fat milk or OJ
Followed by a complex CHO & Protein
Slice of bread or cracker with peanut
butter
Glucagon SQ for severe hypoglycemia
(may cause vomiting, prevent
aspiration)
Honeymoon Period
Blood glucose level initially regulated
by insulin then the child may not need
any insulin from one month to one year
Confuses child and parent
Some MD’s continue to give a very
small amount of insulin during this
time period so that a routine is
established
Consequences of Poor
Management
Cardiovascular
more likely to have high cholesterol and hypertension, CAD
Nephropathy
slow deterioration of kidney function, can eventually result in
kidney failure, also known as end-stage renal disease, or
ESRD.
Neuropathy
nerve damage can range from slight inconvenience to major
disability and even death.
Retinopathy
progressive disease that destroys small blood vessels in the retina,
eventually causing vision problems
The CDE
A diabetes nurse-educator role is as a
resource for information on diabetes
"Certified Diabetes Educator" (CDE)
indicates that the RN has received
board certification.
 Helps patients and families develop a
management plan based child’s age,
work/school schedule, activity level,
and usual eating patterns
Education
 Begins with survival education
 Educate child & family regarding
 Nature of disease, hypo/hyperglycemia
 Meal planning (3 spaced meals, 3 snacks)
 Wearing ID bracelet
 Effective duration, onset & peak action of
insulin
 Injection procedure, rotate sites
 Glucose monitoring, urine testing, record
keeping
 Exercise regime
Nursing Diagnosis
 Risk for injury R/T:____________________
 Fear R/T :____________________________
 Risk for ineffective coping R/T:___________
_______________________________________
 Imbalanced nutrition: more than body requirements
R/T_________________________________________
Nursing Diagnosis
 Risk for non-compliance R/T _______________
 Risk for ineffective therapeutic management R/T
____________________________________________
 Knowledge deficit R/T_______________________
 Altered family processes R/T __________________
Future Diabetic
Management
Insulin inhalers
Mouth sprays
Patches
Pills
Implantable pumps
Disorders of the Thyroid
Congential Hypothyroidism
Acquired Hypothyroidism
Hyperthyroidism
CONGENITAL
HYPOTHYROIDISM
Disorder at birth
Body is producing insufficient
thyroid hormone to meet metabolic
needs caused by absent or
underdeveloped thyroid gland
If not treated can lead to MR
Detected in Newborn Screen
Incidence and Etiology
Caused by defect in the embryonic
period in thyroid glad production
Also caused by inborn error of thyroid
hormone synthesis (an inherited
autosomal recessive trait)
 Can be secondary to pituitary
dysfunction
Thyroid gland is unable to produce T3
and T4
CONGENITAL
HYPOTHYROIDISM
Mottled skin
Large fontanel
Large tongue
Hypotonia/slow
reflexes
Distended
abdomen
Low T4 < 6, High
TSH > 40
CONGENITAL
HYPOTHYROIDISM
An infant with a low T4 <6 and a
TSH value exceeding 40 mU/ml is
considered to have primary
hypothyroidism until proven
otherwise
CONGENITAL
HYPOTHYROIDISM
Treated with lifelong thyroid
replacement therapy
Synthroid 10-15 mcg/kg/day
Monitor G&D and Thermoregulation
Labs q 2 wks then q 3 mos *** look for
upper range of normal
Med compliance
Teach parents to monitor for
hyperthyroidism
Outcome
Prevention of mental retardation –
newborn screening on all babies
Early treatment has had significant
impact on morbidity
Most children progress to within
normal ranges on developmental
assessment
Poor prognosis in more severe cases
Signs of Medication
induced Hyperthyroidism
Nervousness/anxiety
Diarrhea
Heat intolerance
Weight loss
Increased HR
Acquired Hypothyroidism
(Hashimoto’s disease)
Thyroid produces inadequate
levels of thyroid hormone > age 2
T4 decreases, TSH rises
Autoimune disorder
Antibodies and developed against thyroid
gland
Gland becomes inflamed, infiltrated by
antibodies and destroyed
Etiology
Primary (Hashimoto’s thyroiditis)
Most common
Autoimmune
Childhood, adolescents, females>males
Secondary
associated with other conditions that
affect the thyroid
Pituitary and hypothalmic dysfunction
Tertiary
Radiation, surgery, trauma
Acquired Hypothyroidism
Goiter
Dry, thick skin
Coarse but thinning
hair
Fatigue
Cold intolerance
Delayed puberty
and menses
Decelerated growth
Edema around eyes,
face and hands
Constipation
Sleepiness
Mental decline but
mental retardation
or neurologic
sequelae are not
problem
Acquired Hypothyroidism
Treatment
 Thyroid hormone replacement-Synthroid
Starting dose 10 -15 mcg/kg/day
Administration of increasing amounts over 4-8 weeks to
avoid symptoms of hyperthyroidism
Taken 30-60 minutes before meals for optimal
absorption
Repeat thyroid function test one month should
see normalization of TSH
Requires lifetime follow up
Dose and adjustments based on clinical
evaluation & TSH
Prognosis is good if kept euthyroid (normal)
Acquired Hyperthyroidism
(Grave’s Disease)
A hyperfunction of the thyroid gland
Produces excessive circulating
thyroid hormone (T3 and T4)
Four times more common in girls
Occurs between the ages of
12 – 14 yrs. (puberty)
Manifestations develop gradually
with an interval between onset &
diagnosis of 6 to 12 months
Genetics involved
Follows a viral illness or period of
stress
Grave’s Disease
Cardinal Signs & Symptoms:
Emotional liability
Physical restlessness at rest
Decreased school performance
Excessive appetite without weight
gain
Fatigue
Grave’s Disease
Physical Signs & Symptoms:
Increased HR
Palpitations
Widened pulse pressure
Exothalmos
Hair fine, unable to curl
Diarrhea
Poor attention span
Grave’s Disease
Physical Signs & Symptoms:
Wide-eyed
expression with lid
lag
Fine tremors
Increased
perspiration/heat
intolerance
Systolic murmurs
Emotional liability
Insomnia
Grave’s Disease
Thyroid Storm
Acute Onset
Severe irritability & restlessness
Vomiting and diarrhea
Hyperthermia
Hypertension
Severe tachycardia
Prostration
May progress to death
Grave’s Disease
Diagnosis:
Elevated thyroid function studies,
low TSH, high T4
Management:
To suppress thyroxine
PTU - propythioracil
MTZ – methimazole
Subtotal thyroidectomy
Ablation with radioiodine
Grave’s Disease
Nursing Care:
Quiet un-stimulating environment
conducive to rest
Maintain a regular routine to
minimizing stress of coping with
unexpected demands
Physical activity is restricted
Tire easily, experience muscle
weakness and are unable to relax
to recoup their strength
Grave’s Disease
Nursing Care
Increased need for calories to meet their
metabolic rate
Offer 5-6 moderate meals
throughout the day, and vitamin
supplements
Stress good hygiene because of
excessive sweating
Once therapy is instituted observe for
side effects of medications
Monitor for: Neutropenia,
Hepatotoxicity, Bone density
Grave’s Disease
Nursing Care:
If surgery is planned administer iodine
a few weeks before the procedure
Mixed in a strong-tasting fruit juice
given through a straw
Fear of having throat cut is real
Post-op position neck slightly flexed
and observe for bleeding
Supplemental thyroid hormone then for
life
Hypothyroidism
Hyperthyroidism
Tiredness/fatigue
Nervousness/anxiety
Constipation
Diarrhea
Cold intolerance
Heat intolerance
Dry, thick skin
Smooth, velvety skin
Edema of face, eyes,
hands
Prominent eyes
Decreased growth
Accelerated linear growth
Decreased activity/energy Emotional liability
Muscle hypertrophy
Muscle weakness
Decreased heart rate
Increased heart rate
Growth Hormone
Deficiency
Failure of the pituitary to produce growth
hormone
Affected boys=girls
Boys tend to be evaluated more
75% cause is idiopathic
Can be a result of injury and destruction of
anterior pituitary gland from
Brain tumor
Infection
radiation
Symptoms
Normal size and weight at birth
Within first few years child will fall
below the 3rd percentile on growth
chart
Late onset of puberty
Delayed dentition
High-pitched voice
Child-like face with large forehead
Criteria for Suspecting
Growth Hormone (GH)
Deficiency
Consistently poor growth (<5
cm/yr)
Growth rate more than two
standard deviations below the
mean for age
Downward deviation from the
previous growth curve
Assessment and
Diagnosis
Evaluate family history
Prenatal/birth history R/O pituitary
tumor
Growth charts
Diagnosis
X ray, MRI to study bone age
Pituitary function tests
Management
IM recombinant human growth
hormone 2-3 times per week
Given at bedtime when GH usually
peaks
GH is a powder that needs to be mixed
with diluent
Parents/child need teaching
Rapid growth is often painful, pain
management is needed
Nursing Considerations
Speak to child in age appropriate
manner (be careful not to address as a
younger child)
Be discrete when providing step
stools, etc
Provide with anticipatory guidance for
adolescence
Dress in clothing that reflects age not size
Choose sports that height is not a requirement
Case Study
A 14-year-old female with Type I diabetes
mellitus, has the flu and stayed home
from school today. Her mother reports
that she doesn’t have much of an
appetite and can only get her to eat
toast and drink a little tea. She calls the
nurse in the pediatric office. If you were
the nurse…
What questions will you ask the
mother to assure a complete
assessment?
What instructions would you give
regarding insulin dose?
If urinary ketones were present,
what advice would you offer the
client?
A 10-year old type 1 diabetic client tells
the school nurse that he has some
early signs of hypoglycemia. The
nurse recommends that the child:
1.
2.
3.
4.
Take an extra injection of regular insulin
Drink a glass of orange juice
Skip the next dose of insulin
Start exercising
An adolescent with Type I diabetes has had
several episodes demonstrating lack of
diabetic control. The nurse teaches the
client by stating: “The best way to
maintain control of your disease is to:
1.
2.
3.
4.
Check your urine glucose three times a week
Check the HgA1C every 3 months and every 6
months when stable
Check your BG QID and HgA1C every 3 months
Check glucose daily as long as you feel well
A 10-year-old diabetic girl comes to the office of the
school nurse after recess. She was just out of
school for an extended illness and reports that
she returned to her usual insulin dosing schedule
today. The nurse notices she is nervous with hand
tremors, pale, sweaty, and complaining of
sleepiness. The nurse suspects:
1.
2.
3.
4.
Exercise-induced hypoglycemia
Hyperglycemia caused by increased intake at lunch
Ketoacidosis caused by infection
The child is avoiding returning to class
After being diagnosed with Hyperthyroidism, a
teenager begins taking PTU for treatment
of the disease. What symptom would
indicate to the nurse that the dose may be
too high?
1.
2.
3.
4.
Weight loss
Polyphagia
Lethargy
Difficulty with school work