peds exam 3 (endocrine)

Type 1 diabetes

• Characterized by destruction of pancreatic beta cells, usually leading to an absolute insulin deficiency  

• aka low insulin levels  

type 2 diabetes

• Arises because of insulin resistance combined with relative insulin deficiency  

• normal insulin levels but it’s resistant to glucose and can’t take it into cell

sample diet menu for a child with diabetes mellitus

• PB&J: fruit spread instead of jelly/jam

• Mac and cheese: instead of regular pasta, use chickpeas or veggie noodles

food management in diabetes happens in 2 ways

• Constant carbohydrate​

• Carbohydrate (“carb”) counting

constant carbohydrate

• Same amount of carbohydrates for each meal​ so we can see how much insulin is needed

• Usually a starting place and then move to carbohydrate counting

carb counting

• Counting the grams of carbs in foods to be eaten​

• Insulin given matches the number of grams of carbohydrate​

• good for calculating I/C ratio

I/C ratio

insulin to carb ratio

• usually one unit of insulin for each 10 g of carbohydrate

• corrects what you’re abt to eat

I/C ratio protocol

• Check blood sugar 2 hours after meals​

• Adjust I/C ratio as needed​

• May vary with each meal​

• more insulin may be needed at dinner bc we eat more

correction factor (CF)

• The Correction Factor tells you how many points the blood sugar will be lowered by 1 unit of rapid acting insulin.

• corrects glucose before you eat​

how to use CF ratio

• Used in combination with the I/C Ratio calculation to correct high blood sugars before meals.​

• The CF can vary at different meals/times of day according to the person’s needs.

CF factor calculation

• blood glucose- target (will be given)= amount of correct

• amount to correct/ correction factor (will be given)= correction bolus

• if blood sugar is below target, don’t give correction amount, just I/C amount (aka amount for when your about to eat)

glucose levels

• 70-100

  • 80-100 in older kids

• we don’t want it below 120

s/s of hyperglycemia

• glucose in urine

• lots of H2O drinking

• tachycardia

• polyuria

• tachypnea

• thirsty*

• ketones in blood and urine*

• sweet breath*

• disoriented*

• unconscious*

*= DKA s/s

why are there ketones in urine with DKA

• since insulin can;’t bring insulin into cell or there is an insulin deficiency, body uses protein then fat

• fat gets broken down into ketones in blood (acid) which goes into urine & lungs (sweet breath)

Urine testing for ketones

not routinely used EXCEPT testing is helpful when done every 3 hours during illness and whenever the glucose level is 240 mg/dL or higher when illness is not present  

insulin pumps

reserved for the kids who are the most fragile

rapid insulin

eat within 15-20 mins of getting it

regular insulin

eat within 30 mins of getting it

drinking w diabetes

be careful bc alcohol has a LOT of sugar and can affect glucose for 24 hrs

• check sugar regularly before, during, and 24 hours after drinking

Why do we rotate the injections sites?​

• bc absorption rate is different depending on site

• buttock is best place but kids don’t rlly like it

• fast absorption= short duration

education w insulin pumps

• they can shower pump but not go in pool

• and don’t spend too long in the sun bc it can affect the medicine

tx for hypoglycemia

rule of 15

rule of 15

• 15 grams of a simple carb

• check glucose in 15 mins

rule of 15: simple carbs

• hard candy

• juice

• glucose tab

• glucose gel*

why are glucose gels the best

bc they don’t need to be conscious to take it and you can just squirt it in their cheek

rule of 15: check glucose in 15 mins

• once its in therapuetic range, give complex carb w protein to maintain level

  • ex: crackers w PB or cheese

sick day guidelines (aka when a kid w diabetes is sick)

• seek medical attention for fever or signs of infection

• monitor serum glucose levels more often

• required dose of insulin may be increased

• don’t skip doses of insulin

• continue to maintain food and fluid intake

• monitor urine for ketones

1st action in hypoglycemia

• get blood sugar

• quick assessment

s/s of hypoglycemia

• cold clammy skin

• tachycardia

• dizziness

• sweating

• feeling shaky and irritable

hypoglycemia in a hospital setting

give glucagon sub q or dextrose bolus (D-5W) then constant infusion to keep it elevated

questions to ask when someone comes in w suspected hypoglycemia

• What were you doing before

• when was the last time he took his insulin

• was he doing something strenuous or sleeping

• did he take his glucose that morning 

VS in hypoglycemia

if VS are not stable even after giving carbs and dextrose, give more carbs

regular insulin peak

2-3 hours

long acting insulin peak

no peak

 What would you teach diabetics about alcohol use and managing diabetes?

• check glucose before, during, and for at least 24 hours after 

• Hydrate while drinking

• Have some food with the alcohol 

• Drink light beer or a seltzer bc it is lower in sugar 

• Can add diet sodas instead of the regular sodas and drink (diet rum and coke instead of rum and coke)

questions to ask when someone comes in w suspected hyperglycemia

• When was the last time insulin was taken

• How much and what type of insulin did they take 

• Has this happened before 

• are they vomiting? How often?

• When is the last time they voided 

• Dip urine to see if there is ketones - see if the parents did that

questions to ask when someone comes in w suspected hyperglycemia w N/V: When is the last time they voided 

worried abt dehydration, especially if they’ve been vomiting

• no pee= dehydration

VS and electrolytes w DKA

• BP = low (bc of dehydration)

• HR = higher because trying to compensate for the dehydration 

• RR = high because compensating for the acidosis (Kussmaul)

• Temp = high because of possible infection or the dehydration 

• Potassium = high because of trying to lessen the acidosis

contraindicated orders in DKA

• LR

• NPH insulin

• Private room

indicated orders in DKA

• bed rest with bathroom privileges

• Continuous ECG monitoring

• CBC, BMP stat

• Intake and output with urinary output every hour

• Glucose checks every hour

• regular insulin IV infusion

DKA results from

• progressive deterioration with dehydration

• electrolyte imbalance

• acidosis

• coma

signs of DKA

• vomiting more than twice in a 6hr period

• more than 5 diarrheal stools in a day

• change in mental status

• high temp

• sugar >400

• ketones in urine

• acetone breath

• signs of bacterial infection

• dyspnea

• oliguria

• dysuria (UTI signs)

IV insulin

needs 2 nurse sign off

How fast can you bring down a glucose level? 

No more than 80-100 per hour 

• thats why we give dextrose w insulin drip once glucose hits 300 range

is someone has hyperkalemia with DKA was should we do

• Continuous ECG monitoring to pick up any arrhythmias  

• Elevated potass can give you muscle weakness  

• Make sure we give insulin and IVF as ordered bc if glucose goes up usually potass goes up  

• Monitor for falls and seizures  

• Resp status  

precocious puberty

Onset of puberty is too early

• secondary sexual characteristics 

precocious puberty ages

• Too early for boy: <9 yrs 

• African American girl: before 6 

• White: before age of 7 

3 types of precocious puberty

• central precocious puberty (80%) 

• peripheral precocious puberty  

• incomplete precocious puberty 

how is central precocious puberty treated

• leuprolide acetate

  • Lupron

  • Depot

leuprolide acetate

• Slows prepubertal growth to normal rates

• Treatment is discontinued at the age at which normal pubertal changes would resume

thyroid dysfunction in kids is

usually hypothyroidism

hypothyroidism

Low levels can lead to low growth (especially of brain)= developmental delays 

• Part of newborn screening (thyroid levels) 

 

Juvenile hypothyroidism  

• Rarely occurs from dietary iodine insufficiency in the US  

• Early detection important: it is part of the newborn screening test

Juvenile hypothyroidism s/s

• Decelerated growth

• Myxedematous skin changes

• Dry skin

• Sparse hair

• Periorbital edema

• Constipation

• sleepiness

• Mental decline

Juvenile hypothyroidism s/s in infants

• “quiet baby”

• prolonged jaundice

• constipation

tx for hypothyroidism

• synthroid (levothyroxine) (to replace hormones) 

hyperthyroidism (Grave’s disesae)

Seen in babies w moms who have hyperthyroidism 

• increased levels of T4 and T3

• suppressed TSH levels

s/s of hyperthyroidism

Enlarged thyroid gland and exophthalmos

tx for hyperthyroidism

• Antithyroid drugs (PTU & methimazole)

  • watch leukopenia w/ methimazole  

• Subtotal thyroidectomy  

• Ablation with radioiodine  

Labs for thyroid dysfunction kids:  

• Total T4 

• Total TSH 

• Not rlly T3 

Signs that show meds are working in thyroid dysfunction

• TSH should be normal (goes up when T4 goes low) 

• T4 should also be normal 

Thyrotoxicosis or thyroid storm/crisis  

• Life threatening  

• Sudden release of thyroid hormones

s/s of Thyrotoxicosis or thyroid storm/crisis  

Acute onset of:

• severe irritability and restlessness

• vomiting & diarrhea

• hyperthermia

• hypertension

• tachycardia

goiter

Hypertrophy of the thyroid gland

congenital goiter

Usually results from maternal ingestion of antithyroid

drugs or iodides during pregnancy

acquired goiter

from increased secretion of pituitary TSH

how to get rid of goiter

Replacement of thyroid hormone (synthroid)

priority in goiter

airway

diabetes insipidus

• disorder of the posterior pituitary gland  

• Too little ADH (vasopressin)

• Pee too much 

s/s of Diabetes insipidus

• Bed wetting (first s/s)

• polyuria

• polydypsia

Diabetes insipidus in infants

• Irritability is relieved with feedings of water but not milk  

• Dehydration often occurs  

Therapuetic management for DI

• replacement of vasopressin

• Strict I&O

SIADH

Too much ADH 

s/s of SIADH

• Hypotonicity (delusional hyponatremia) 

• Fluid retention (no urine output) 

• Anorexia

• N/V

• irritability

• personality changes

therapeutic management of SIADH

• restrict fluid 

• Strict I&O 

• Seizure precautions

Hyperpituitarism 

• Excessive GH before closure of the epiphyseal shafts results in proportional overgrowth of the long bones until the individual reaches a height of 8ft or more

• Also accompanied by rapid & increased development of muscle and viscera 

• If over secretion of GH occurs after the closure of epiphyseal then they develop acromegaly

• Grow fast during puberty and then not during adult hood

• can be caused by tumor

s/s of Hyperpituitarism 

• Acromegaly (overgrowth of head, mouth, lips, nose, tongue, jaw, and sinuses) 

• Separation and malocclusion of teeth in enlarged jaw  

• thickened deeply creased skin  

• increased facial hair  

• disproportion of face and cerebral division of skull  

dx of Hyperpituitarism

H&PE and evidence of inc GH

therapeutic management of Hyperpituitarism

• surgical removal of tumor (if present) 

• destruction of pituitary tissue by radiation and radioactive implants

Hypopituitarism 

• diminished or deficient secretion of pituitary hormones  

• gonadotropin deficiency (absent or regressed secondary sex characteristics)  

• growth hormone deficiency (stunted somatic growth) 

• thyroid stimulating hormone (hypothyroidism) 

• adrenocorticotropic hormone deficiency (adrenal hypofunction) 

s/s of Hypopituitarism 

• usually grow normal during 1st yr and then follow a slow growth curve that is under the 3rd percentile 

• may appear overweight or obese

• dentition

• sexual maturation is delayed, but otherwise normal unless gonadotropin hormone deficient

Hypopituitarism: dentition

the development, arrangement, and number of teeth in the mouth

dx of Hypopituitarism

absent or subnormal reserves of pituitary GH (GH stimulation test) 

growth failure

an absolute height of less than -2 standard deviation for age or a linear growth velocity consistently less than -1 SD for age

s/s of Growth Hormone deficiency

• Short stature but proportional height and weight

• Delayed epiphyseal closure

• delayed bone age proportional to height

• Premature aging common in later life

• Increased insulin sensitivity

Hypopituitarism tx

give GH supplements to make bones grow

• discontinued when growth velocity is < 1 in/year and bone age is 14 I n girls and 16 in boys