Endocrine Disorders Endocrine Disorders in the Pediatric Clientin the Pediatric Client

MARLENE MEADOR, RN, MSN, CNEMARLENE MEADOR, RN, MSN, CNE

Understanding the Understanding the endocrine system in endocrine system in childrenchildren

Puberty brings many changesPuberty brings many changes ↑↑GH releasedGH released ↑ ↑ production of LH and FSH in girlsproduction of LH and FSH in girls

Development of sexual characteristicsDevelopment of sexual characteristics Feedback mechanism in placeFeedback mechanism in place

Collecting data during an Collecting data during an endocrine assessmentendocrine assessment

Percentiles on weight and heightPercentiles on weight and height Distinguishing facial features, abd. fatDistinguishing facial features, abd. fat Onset of pubertyOnset of puberty Routine NB screeningRoutine NB screening Blood glucose levelsBlood glucose levels Detection of chromosomal disordersDetection of chromosomal disorders

Pancreatic dysfunctionsPancreatic dysfunctions

EtiologyEtiology Preclinical stagePreclinical stage ManifestationsManifestations DiagnosisDiagnosis

Therapy for diabetes in Therapy for diabetes in childrenchildren

Diagnosis:Diagnosis: Under 18?Under 18? Type I diabetesType I diabetes

Clinical therapy combines:Clinical therapy combines: insulininsulin nutritionnutrition exercise regimenexercise regimen psychosocial supportpsychosocial support

Insulin therapyInsulin therapy

Insulin reviewInsulin review

Rapid (Lispro/Humalog)Rapid (Lispro/Humalog) Short acting (regular)Short acting (regular) Intermediate acting (NPH, Lente)Intermediate acting (NPH, Lente) Long acting (Lantus/Ultralente)Long acting (Lantus/Ultralente)

Basal-bolus therapyBasal-bolus therapy

ADA recommendations for childrenADA recommendations for children Basal insulin administered 1-2x day; bolus of Basal insulin administered 1-2x day; bolus of

rapid acting with each meal and snackrapid acting with each meal and snack Method of this therapy:Method of this therapy:

Lower glucose levelsLower glucose levels Stabilize glucose levelsStabilize glucose levels Eliminate ketonesEliminate ketones Insulin dose adjusted to BS readings 4x dayInsulin dose adjusted to BS readings 4x day

Basal bolus, cont.Basal bolus, cont.

BS monitored 4-8x day; 1x a week at BS monitored 4-8x day; 1x a week at midnight and 3AMmidnight and 3AM

Therapy can be achieved with 3+ insulin Therapy can be achieved with 3+ insulin injections a day or by pumpinjections a day or by pump

There must be consistent carb countsThere must be consistent carb counts Routine exerciseRoutine exercise

Factors which may affect Factors which may affect insulin dosage in childreninsulin dosage in children

StressStress InfectionInfection IllnessIllness Growth spurts (such as puberty)Growth spurts (such as puberty) Meal coverage for finicky toddlersMeal coverage for finicky toddlers Adolescents concerned about weight Adolescents concerned about weight

gain not wanting to eat AM snackgain not wanting to eat AM snack

External insulin infusion External insulin infusion pump in childrenpump in children

AdvantagesAdvantages Delivers continuous infusionDelivers continuous infusion Maintain better controlMaintain better control # of injection sites# of injection sites hypo/hyper episodeshypo/hyper episodes More flexible lifestyleMore flexible lifestyle Eat with more flexibilityEat with more flexibility Improves growth in childImproves growth in child

DisadvantagesDisadvantages Requires motivationRequires motivation Requires willingness to be Requires willingness to be

connected to deviceconnected to device Change sites every 2-4 daysChange sites every 2-4 days More time/energy to monitor More time/energy to monitor

BSBS Syringe, cath changes every Syringe, cath changes every

2-3 days2-3 days Infection may occur at siteInfection may occur at site Wt gain common when BS is Wt gain common when BS is

controlled controlled

Insulin therapy, cont.Insulin therapy, cont.

Monitored every 3 months by hemoglobin Monitored every 3 months by hemoglobin A1cA1c

Represents amt of glucose attached to Represents amt of glucose attached to hemoglb over period of timehemoglb over period of time

Roughly 120 daysRoughly 120 days Good predictor of levels over 6-8 wksGood predictor of levels over 6-8 wks

Nursing Management at Nursing Management at the time of diagnosisthe time of diagnosis

Child is admitted to hospitalChild is admitted to hospital Nsg assessments directed toward:Nsg assessments directed toward:

HydrationHydration LOCLOC Hourly monitoring of BSHourly monitoring of BS Dietary and caloric intakeDietary and caloric intake Ability of family to manageAbility of family to manage

““Sick Day guidelines”Sick Day guidelines”

Days that child is illDays that child is ill Attention to glycemic controlAttention to glycemic control BS levels more often than routineBS levels more often than routine DO NOT SKIP INSULIN!DO NOT SKIP INSULIN! Factors key to preventing DKAFactors key to preventing DKA

Home TeachingHome Teaching

Incorporate into the family lifestyleIncorporate into the family lifestyle ““Honeymoon phase”Honeymoon phase” Community resourcesCommunity resources Recognizing the cognitiveRecognizing the cognitive

levels at time of teachinglevels at time of teaching

Diabetic KetoacidosisDiabetic Ketoacidosis

Review of pathoReview of patho CausesCauses Criteria for diagnosis of DKACriteria for diagnosis of DKA

BS levels> 300BS levels> 300 Serum ketonesSerum ketones ↓ ↓ bicarbonatesbicarbonates Acidosis (pH <7.3)Acidosis (pH <7.3)

Treatment for DKATreatment for DKA

Fluids (boluses)Fluids (boluses) Wean off IV insulin when clinical stableWean off IV insulin when clinical stable Oral feedings introduced when alertOral feedings introduced when alert Prevention of future episodesPrevention of future episodes

Type II diabetes in Type II diabetes in childrenchildren

There is insulin resistanceThere is insulin resistance Fatty tissue produces hormoneFatty tissue produces hormone Hormone desensitized to insulinHormone desensitized to insulin Can result in hyperinsulinismCan result in hyperinsulinism Signs and symptomsSigns and symptoms

Acanthosis nigricansAcanthosis nigricans

Inborn errors of metabolism

Phenylketonuria Galactosemia Defects in Fatty Acid Oxidation Maple syrup urine disease

Phenylketonuria (PKU)

Autosomal recessive Liver deficiency Treatment/education Counseling for future pregnancies

GalactosemiaGalactosemia

Carbohydrate metabolic dysfuntionCarbohydrate metabolic dysfuntion Autosomal recessiveAutosomal recessive Liver enzyme deficiency Liver enzyme deficiency Implications/symptomsImplications/symptoms Treatment/managementTreatment/management

Defects in fatty acid oxidation

Defects result in fatty acid oxidation Most common of inborn errors Most common presentation Diagnosis/treatment

Maple syrup urine disease

(MSUD) Disorder of amino acid metabolism Diagnosis made by UA Treatment/management

Nursing measures for metabolic disorders

Genetic counseling Dietary teaching.compliance Mixing special preparations Mainly supportive