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 body’s 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 > 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 can’t 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 won’t 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_id=2733#injection_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, can’t 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 P’s • 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 • Mild-moderate • Shaky/sweaty • Hungry • Pale • Headache • Confusion • Disorientation • Lethargy • Change in behavior • Severe • Inability to swallow • Seizure/convulsion • Unconsciousness

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 > 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