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Endocrine 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 are either • Hypofunction • Primary • Secondary • 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 1 Diabetes Type 1 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 fasting glucose 70-110mg/dl • Glycosated Hemoglobin (Hgb A1C) < 6.0% Initial Clinical Manifestations 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 When to Monitor for DKA • Abdominal pain • Nausea and vomiting that persists for over 6 hours • More than five diarrheal stools in 1 day • A 1- or 2-day history of polyuria and polydipsia • Has illness (e.g., viral or other) and is unable to eat Type 1 Diabetes Treatment • Multidiscipline • Promote normal growth and development • Optimal glucose control • Minimal complications • Adjustment to disease • Treatment consists of • • • • Insulin replacement Diet Blood glucose monitoring Exercise Diet Therapy • Consistent intake & timing of food to correspond to insulin prescribed • Well-balanced, enough caloric intake to support growth and development • Three meals, snacks spaced throughout the day • No diet, sugar-free foods • Don’t omit meals 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 Blood Glucose Monitoring Finger stick glucose monitoring several times a day Urine testing for glucose and ketones Teach good record keeping Self-management at age appropriate level 2-6 choose food, clean finger for stick 4-6 dip own urine 6-8 Blood glucose management 8-10 insulin injections, keep 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 growth Can be administered twice daily 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 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 • Must be 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 • Rapid-acting insulin only is used to manage hyperglycemia associated with illness • Monitor fluids, may require extra oral fluids while ill “Sick Day” Guidelines • Seek medical attention for fever or other signs of infection. • Monitor the blood glucose levels more often than routine (1 to 4 hours). • Test urine ketones when the blood glucose level is greater than 200 mg/dL. • Do not skip doses of insulin. • Large fluid intake (drinks with carbohydrates) is essential if the child cannot eat as usual. • If the child cannot consume adequate amounts of fluids, seek medical attention. Hyperglycemia BG > 110 Gradual onset Lethargic, fatigue Confused Weakness Polyuria Polydypsia Polyphagia 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 meals or snacks Too much insulin-wrong dose Hypoglycemia BG < 70 Rapid onset • Irritable, nervousness • Difficulty concentrating • Shaky feeling, tremors, hunger • Diplopia • Pallor • Weakness • Headache, dizziness • Sweating • Unconsciousness and convulsions Treatment of Hypoglycemia Give 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) Nursing Considerations 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 Considerations • Provide emotional support • Encourage growth and development • Identify home care needs Disorders of the Thyroid • Congenital Hypothyroidism • Acquired Hypothyroidism • Hyperthyroidism Congenital Hypothyroidism 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 severe cognitive impairment • Detected in Newborn Screen CONGENITAL HYPOTHYROIDISM • 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 Clinical Manifestations • 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 is considered to have primary hypothyroidism until proven otherwise Treatment • Treated with lifelong thyroid replacement therapy • Synthroid 10-15 mcg/kg/day • Taken 30-60 minutes before meals for optimal absorption • Crush pill and mix with formula or breast milk Parental Education • Monitor Growth and Development and Thermoregulation • Labs every 2 weeks then every 3 months look for upper range of normal • Stress medication compliance • Teach parents to monitor for medication induced hyperthyroidism Signs of Medication induced Hyperthyroidism • Nervousness/anxiety • Diarrhea • Heat intolerance • Weight loss • Increased HR Outcome • Prevention of cognitive impairment– 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 Acquired Hypothyroidism (Hashimoto’s disease) Acquired Hypothyroidism • Autoimune disorder • Antibodies and developed against thyroid gland • Gland becomes inflamed, infiltrated by antibodies and destroyed • Thyroid produces inadequate levels of thyroid hormone > age 2 • T4 decreases, TSH rises Types of Acquired Hypothyroidism • 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 Clinical Manifestations • Decelerated • Goiter growth • Dry, thick skin • Edema around eyes, face and • Coarse hair hands • Fatigue • Constipation • Cold intolerance • Sleepiness • Delayed puberty and • Mental declinenot permanent menses cognitive impairment Acquired Hypothyroidism Treatment • Thyroid hormone replacement-Synthroid • Starting dose 10 -15 mcg/kg/day • Taken 30-60 minutes before meals for optimal absorption • Teach child to swallow pill or crush • 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) Acquired Hyperthyroidism • 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 Clinical Manifestations • • • • • • • • • • Emotional liability Physical restlessness at rest Decreased school performance Excessive appetite without weight gain Fatigue Hair fine, unable to curl Diarrhea Poor attention span Insomnia Increased perspiration/heat intolerance Clinical Manifestations • Increased HR • Palpitations • Widened pulse pressure • Exothalmos • Wide-eyed expression with lid lag • Fine tremors • Systolic murmurs Thyroid Storm • Acute Onset • • • • • • • Severe irritability & restlessness Vomiting and diarrhea Hyperthermia Hypertension Severe tachycardia Prostration May progress to death Treatment • To suppress thyroxine • PTU - propythioracil • MTZ – methimazole • Subtotal thyroidectomy • Ablation with radioiodine Nursing Care • Needs 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 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 • If taking PTU or MTZ observe for side effects of medications • Neutropenia and Hepatotoxicity 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 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 Practice Questions! A 10-year old with type 1 diabetes 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 four times a day and HgA1C every 3 months Check glucose daily as long as you feel well A 10-year-old girl with type 1 diabetes 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 feeling drowsy. 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 A child with type 1 diabetes 7:00 am blood glucose is 189. The previous evening at 5:30 pm the child injected rapid insulin and NPH, ate dinner and had a 10 pm snack. The nurse concludes (select all that apply) 1. Rapid insulin dose may be to low 2. NPH insulin dose may be to low 3. NPH insulin dose may be to high 4. The child ate too little dinner 5. The child ate too much snack • The nurse is teaching a parent of a child with type 1 diabetes about the different types of insulin. The nurse assumes the parent understands rapid insulin peak times if the parent states that when injecting at 6:45 am, be sure the child does not miss: 1. 7:00 AM Breakfast 2. 12:30 PM Lunch 3. 6:30 PM Dinner 4. 10:00 AM Snack