Endocrine Stressors and Adaptation

Common Pediatric Endocrine Disorders

Type I DiabetesCongenital HypothyroidismAcquired Hypothyroidism (Hashimoto’s

Disease)Hyperthyroidism (Graves disease)Growth Hormone Deficiency

The Endocrine SystemGlands-Hormones-Endocrine disorders

Hypofunction Hyperfunction

PrimarySecondary

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 pubertyAbrupt onsetGenetic 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.

EtiologyAutoimmune

process causes destruction on insulin-secreting cells in the pancreas

At dx 90% of beta cells are destroyed

Type 1 DiabetesNo 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 A1C1.8 to 4.0 is normal> 6.0 = DM

Diagnosis:fasting: >126mg/dl Random (non-fasting): ≥ 200mg/dl with classic signs (next slide)

Signs & Symptoms

PolyuriaPolydipsia PolyphagiaFatigue Blurred visionHeadacheShortened attention span

Mood changes

Diabetic Ketoacidosis(DKA)

Medical EmergencyAs glucose levels rise, child will

progress into DKA if not treatedBlood 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

MultidisciplineGoal: 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 foodsdon’t omit meals

Diet TherapyNo 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

ExerciseEncouraged, 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 MonitoringGlucose monitoringUrine testing for ketonesRecord keepingSelf-management at age

appropriate level2-6 choose food, clean finger

for BG4-6 dip own urine6-8 BGM8-10 insulin injections, diary10-14 nutritional decisions12-18 full management

InsulinPrecise dose cannot be predicted

Amount is based upon average capillary or serum blood glucose levels

Will change based of G & DCan be administered TID SQ by needle/syringe, pen or by insulin/portable pump

Types of InsulinSynthetic Human Insulin

Rapid acting Lispro (Humalog) Aspart (Novolog)

Fast acting Regular ®

Intermediate NPH (N)

Mixed (70/30) Long Acting

Glargine (Lantus) Ultra Lente

Typical ManagementThe peak of the insulin should

occur Post-Prandial (after meal) to avoid hypoglycemia

InsulinAlternate 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

PumpsAdvantages

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

ILLNESSalters 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 onsetLethargicPolyuriaPolydypsiaDulled sensorium, confusedWeakness, fatigue, lethargy

Glucose 250 mg/dl Large ketones in blood & urine Blurred vision Ketoacidosis Coma

HypoglycemiaBG < 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 & Symptomsof HypoglycemiaRapid onsetIrritable, nervousnessDifficulty concentratingShaky feeling, tremors, hungerDiplopiaPallorWeaknessHeadache, dizzinessSweatingUnconsciousness and convulsions

Treatment of Hypoglycemia

Simple concentrated sugarGlucose gel or SL tablets Hard candySugar cubesLow-fat milk or OJ

Followed by a complex CHO & ProteinSlice of bread or cracker with peanut butter

Glucagon SQ for severe hypoglycemia (may cause vomiting, prevent aspiration)

Honeymoon PeriodBlood glucose level initially regulated

by insulin then the child may not need any insulin from one month to one year

Confuses child and parentSome 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

Cardiovascularmore likely to have high cholesterol and hypertension, CAD

Nephropathyslow deterioration of kidney function, can eventually result in kidney failure, also known as end-stage renal disease, or ESRD.

Neuropathynerve 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 CDEA 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 inhalersMouth spraysPatchesPillsImplantable pumps

Disorders of the ThyroidCongential HypothyroidismAcquired HypothyroidismHyperthyroidism

CONGENITAL HYPOTHYROIDISM

Disorder at birthBody is producing insufficient

thyroid hormone to meet metabolic needs caused by absent or underdeveloped thyroid gland

If not treated can lead to MRDetected in Newborn Screen

Incidence and EtiologyCaused by defect in the embryonic

period in thyroid glad productionAlso 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 skinLarge fontanelLarge tongueHypotonia/slow

reflexesDistended abdomenLow 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/dayMonitor G&D and ThermoregulationLabs q 2 wks then q 3 mos *** look for

upper range of normalMed complianceTeach parents to monitor for

hyperthyroidism

OutcomePrevention of mental retardation –

newborn screening on all babiesEarly treatment has had significant

impact on morbidityMost children progress to within

normal ranges on developmental assessment

Poor prognosis in more severe cases

Signs of Medication induced Hyperthyroidism

Nervousness/anxietyDiarrheaHeat intoleranceWeight lossIncreased HR

Acquired Hypothyroidism (Hashimoto’s disease)

Thyroid produces inadequate levels of thyroid hormone > age 2

T4 decreases, TSH risesAutoimune disorder

Antibodies and developed against thyroid gland

Gland becomes inflamed, infiltrated by antibodies and destroyed

Etiology

Primary (Hashimoto’s thyroiditis)Most commonAutoimmuneChildhood, adolescents, females>males

Secondaryassociated with other conditions that

affect the thyroidPituitary and hypothalmic dysfunction

Tertiary Radiation, surgery, trauma

Acquired Hypothyroidism

GoiterDry, thick skinCoarse but thinning

hairFatigueCold intoleranceDelayed puberty

and menses

Decelerated growthEdema around eyes,

face and handsConstipationSleepiness 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 glandProduces excessive circulating thyroid

hormone (T3 and T4)Four times more common in girlsOccurs between the ages of

12 – 14 yrs. (puberty)Manifestations develop gradually with

an interval between onset & diagnosis of 6 to 12 months

Genetics involvedFollows a viral illness or period of stress

Grave’s Disease

Cardinal Signs & Symptoms:Emotional liabilityPhysical restlessness at restDecreased school performanceExcessive appetite without weight

gainFatigue

Grave’s DiseasePhysical Signs & Symptoms:

Increased HR PalpitationsWidened pulse pressureExothalmosHair fine, unable to curlDiarrheaPoor attention span

Grave’s DiseasePhysical Signs & Symptoms:

Wide-eyed expression with lid lag

Fine tremors Increased

perspiration/heat intolerance

Systolic murmursEmotional liability Insomnia

Grave’s Disease

Thyroid StormAcute 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 T4Management:

To suppress thyroxinePTU - propythioracil MTZ – methimazoleSubtotal thyroidectomyAblation 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 restrictedTire easily, experience muscle weakness and are unable to relax to recoup their strength

Grave’s DiseaseNursing 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 DiseaseNursing Care:

If surgery is planned administer iodine a few weeks before the procedureMixed 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 HyperthyroidismTiredness/fatigue Nervousness/anxietyConstipation DiarrheaCold intolerance Heat intoleranceDry, thick skin Smooth, velvety skinEdema of face, eyes, hands

Prominent eyes

Decreased growth Accelerated linear growth

Decreased activity/energy Emotional liability

Muscle hypertrophy Muscle weaknessDecreased heart rate Increased heart rate

Growth Hormone Deficiency

Failure of the pituitary to produce growth hormone

Affected boys=girlsBoys tend to be evaluated more75% cause is idiopathicCan be a result of injury and destruction of

anterior pituitary gland from Brain tumor Infection radiation

SymptomsNormal size and weight at birthWithin first few years child will fall

below the 3rd percentile on growth chart

Late onset of pubertyDelayed dentitionHigh-pitched voiceChild-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 DiagnosisEvaluate family historyPrenatal/birth history R/O pituitary tumorGrowth charts

Diagnosis X ray, MRI to study bone age Pituitary function tests

 

ManagementIM recombinant human growth

hormone 2-3 times per weekGiven at bedtime when GH usually

peaksGH is a powder that needs to be mixed

with diluentParents/child need teachingRapid growth is often painful, pain

management is needed

Nursing ConsiderationsSpeak 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. Take an extra injection of regular insulin2. Drink a glass of orange juice3. Skip the next dose of insulin4. 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. Check your urine glucose three times a week2. Check the HgA1C every 3 months and every 6

months when stable3. Check your BG QID and HgA1C every 3 months4. 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. Exercise-induced hypoglycemia2. Hyperglycemia caused by increased intake at lunch3. Ketoacidosis caused by infection4. 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. Weight loss2. Polyphagia3. Lethargy4. Difficulty with school work