paediatric endocinology dr sarah lawrence_compressed (1)

8/17/2019 Paediatric Endocinology Dr Sarah Lawrence_compressed (1)

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Pediatric Endocrinology

Sarah Lawrence

Division of EndocrinologyCHEO


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Type 1 Diabetes


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Epidemiology of Type 1

Prevalence 0.4% of individuals < ! years

"ncreased ris# $o faily e&ers

Si&ling '%

(a$her wi$h dia&e$es )*!%

+o$her wi$h dia&e$es ,*-%

"den$ical $win -0*'0%


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Type 1 Diabetes

% .

e $ a

C e l l s

/ie

ene$ic1redis1osi$ion

Environen$al insul$

2n$i&ody

1osi$ive

Dia&e$es


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Diagnostic Criteria

( 3 .0 ol5L O6

Casual 3 . wi$h sy1$os O6

, hour in O// of 3 .


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"7"/"2L +272E+E7/


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New Onset DM: Baseline labs

lucose8 urea8 crea$8 ly$es8 gas

9rine for glucose and #e$ones

/SH8 $hyroid an$i&odies


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New Onset DM: Diet

000 #cal : 00 #cal5year of age

i.e. ! yo child ; 000 : !00 ; !00 #cal

- eals and - snac#s

Curren$ly use echange sys$e8 &u$ changing$o car&ohydra$e coun$ing S$arch ' g (rui$5Sugar 0 g Dairy ) g


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b!1c " BG le#els


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New Onset $ %ns&lin

Dose y weigh$@ 0.' A 0.'

uni$5#g5day ,5- a8 5- 1

,5- 78 5- H i.e. ! yo8 ,' #g

y age

2 7 ; uni$5year of age 2+ H is '0% of $his P+ dose is '0% of $he

a dose

8 yo

am pm

8N 4H 4N 2H

25 x( 0.5) = 15

Am 10 U Pm 5 U

3.5 N 1.5 H7 N 3 H


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a noon 1 hsa

/wice Daily "nsulin@7PH : 65analogue


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a noon 1 hsa

/hree /ies Daily "nsulin@7PH : 65analogue


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Basal-Bolus Insulin Therapy: Insulin Glargine at

HS and Mealtime Lispro or Aspart

B DL HS

Insulin Glargine or Levemir

Insulin Lispro or Aspart

Time of administration

B, breakfast; L, lunch; D, dinner; HS, bedtime.

Adapted from:

1. Leahy L. !n: Leahy L, "efalu #$, eds. Insulin Therapy. %e& 'ork, %': (arcel Dekker, !nc.; )**).). Bolli +B, et al. Diabetologia. 1;-):111/110.

Type 1 DM


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Basal


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%ns&lin %n'ection (ites

Pic$ure of li1ohy1er$ro1hy

http://images.google.ca/imgres?imgurl=http://www.disetronic-usa.com/files/Images/infusion%2520set%2520rotation%2520images/bad_side.jpg&imgrefurl=http://www.disetronic-usa.com/commonquestions_18.htm&h=148&w=200&sz=7&tbnid=k9RXlYgmqlgJ:&tbnh=73&tbnw=99&hl=en&start=5&prev=/images%3Fq%3Dlipohypertrophy%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG


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%ns&lin ad'&stment: basic principles

7ew onse$8 a#ing daily changes un$il s$a&iliBed

Es$a&lished dia&e$es

High! High sae $ie of day - consecu$ive days "ncrease 0% a$ a $ie

Lo"! 9ne1lained lows ,5wee# sae $ie of day 0*,0% a$ a $ie


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%ns&lin ad'&stment: basic principles/ie of Day "nsulin $o adus$

+orning 1 7

7oon a 6

Su11er a 7

ed 1 6

am #oo# hpm am

$ $

NN


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ypoglycemia

%a&'!

/oo uch eercise5ac$ivi$y for which you did no$ 1lan

7o$ enough food and5or delay in ge$$ing $he

eal5snac#/oo uch insulin

'a*m'#*!


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ypoglycemia

Severe hy1oglyceia lucagon


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D)!: ow common is it*

2$ diagnosis of dia&e$es '*)% 1resen$ wi$h D2

Es$a&lished dia&e$es *0% of 1a$ien$s5year

Cere&ral edea 0.4*% of e1isodes of D2 ,'% or$ali$y8 u1 $o -'% wi$h severe

neurologic defici$s


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Cerebral Edema in D)!

ho is a$ ris#F

"ncreased ris# in new onse$ D+8 ore dehydra$ed and

acido$ic 1a$ien$s

F$rea$en$ fac$ors A ra1id infusion of hy1o*osolar

fluids8 use of &icar&ona$e

/rea$en$ A early in$erven$ion is #ey 6aise HO8 : in$u&a$e8 reduce fluids

+anni$ol8 hy1er$onic saline


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%ns&lin Dose !d'&stment

G&idelines for %nterc&rrent %llness

TDD = Total Daily Dose


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Type + Diabetes in

C,ildren and -o&t,


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Example: 95thPercentile

Tracking

Age BMI

2 yrs 9!" # yrs $!%

9 yrs 2!&" yrs 25!

(or Children8 +" Changes wi$h 2ge

Boys: 2 to 20 years

BMI BMI

BMI BMI


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Genetic and En#ironmental .is/

factors for T+DM E$hnici$y

(eale gender

(aily his$ory /,D+

"n$rau$erine fac$ors +a$ernal his$ory of ges$a$ional dia&e$es

Large for ges$a$ional age =34 #g>

Sall for ges$a$ional age =


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De#elopment of Type + Diabetes

7oral

"nsulin resis$ance

"1aired lucose /olerance

/y1e , Dia&e$es


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!cant,osis Nigricans


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Metabolic (yndrome in -o&t, by

BM%

+ " i

* h , ' * a - o . i / S y

# 0 ) o m '

B, P'/'#*i'


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Treatment of T+DM in -o&t,

Dia&e$es educa$ion for $he faily

Se$$ing glyceic $arge$s H&2c < .0%

Lifes$yle odifica$ion


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Presentation of T1DM #s T+DM

yp' 1 yp' 2

91 $o I overweigh$

Shor$ Course

,'*40% D2

(H /D+ in '*0%

Predoinan$ly whi$e

!'% overweigh$

"ndolen$ course

--% #e$onuria'*,'% D2(H /,D+ 4*00%

+inori$y you$h


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T,yroid Disorders


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Approach to +oitre

23e

"hronic lymphocytic

thyroiditis

43e

+oitro5en,

Dyshormono5enesis

$hyroid Antibodies

Elevated Hypothyroid

$SH

+oitre

Suppressed Hyperthyroid

Normal 6uthyroid


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ypot,yroidism


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ypot,yroidism $ Treatment

+edica$ion@ /hyroine '*00 cg5,5day

+oni$or every ) on$hs un$il grow$h co1le$e8 $henannually@

SS hy1o5hy1er$hyroidisrow$h

Seual a$ura$ion

/SH =ai for 0.,'*' 95L>

: (/4

6echec# /SH 4*) wee#s af$er dose adus$en$


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Approach to +oitre

23e

"hronic lymphocytic

thyroiditis

43e

+oitro5en,

Dyshormono5enesis

$hyroid Antibodies


23e743e: +ra3es

Hashito8icosis

Subacute thyroiditis

$hyroid Antibodies


$SH

+oitre

Normal 6uthyroid


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Gra#es Disease


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as,ito0icosis (&bac&te

t,yroiditis

SH

/ie

4

Hy1er$hyroid 1hase Hy1o$hyroid 1hase


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ypert,yroidism $ Management+edical +anageen$

2n$i$hyroid edica$ions

+e$hiaBole =++"8 /a1aBole/+>

"ni$ial dose@ 0.4*0.) g5#g5day G!*,h

+ain$enance@0.,*0.- g5#g5day G,*,4h

Pro1yl$hiouracil =P/9>

"ni$ial Dose@ 4*) g5#g5day G)*!h

+ain$enance ,*- g5#g5day G ,h =*,4h>

Pro1ranolol"odide

6adioac$ive "odine

Surgery


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ypert,yroidism $ Management

Side Effec$s of 2n$i$hyroid edica$ions@

+ild * 1ruri$is8 rash8 a&doinal 1ain8 neu$ro1enia8

Serious * agranulocy$osis8 ar$hro1a$hy8 lu1us*li#esyndroe8 he1a$i$is


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ypert,yroidism $ Management

+edical +anageen$ * +oni$oring

"ni$ially oni$or G 4*) wee#s un$il /4 s$a&iliBed on

ain$enance doses of ++"5P/98 $hen G -*4 on$hs.

Clinical s$a$us

/48 /SH

enerally con$inue $rea$en$ for , years $hen $ry off $

and oni$or closely for rela1se


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Approach to +oitre

23e

hronic lymphocytic

thyroiditis

43e

+oitro5en,

Dyshormono5enesis

$hyroid Antibodies


23e

"hronic lymphocytic

thyroiditis

43e

"olloid 5oitre

$hyroid Antibodies

Normal 6uthyroid

23e743e

+ra3e9s disease,

Subacute thyroiditis

$hyroid Antibodies


$SH

+oitre


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Subclinical Hypothyroidism

Normal Subclinical Overt

Hypothyroidism Hypothyroidism

TSH N

FT4 N N


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(&mmary /hyroid disorders are coon in children and

adolescen$s

+os$ coonly 1resen$ wi$h goi$re secondary

$o au$oiune $hyroidi$is or a si1le colloidgoi$re

/SH and $hyroid an$i&odies is usually all $ha$ isreGuired $o es$a&lish $he diagnosis

9l$rasound should &e lii$ed $o $hose wi$h a1al1a&le nodule


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(&mmary

/he noral range of /SH ay &e higherin $he 1edia$ric 1o1ula$ion leading $o over*

inves$iga$ion 5diagnosis and $rea$en$ of

$hyroid disorders

+ild eleva$ions of /SH should &e verified

on re1ea$ $es$ing

/SH


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(&mmary

7a$ural his$ory s$udies sugges$ a high

ra$e of s1on$aneous resolu$ion wi$h

au$oiune $hyroid disease and $hus8

re1ea$ $es$ing should &e done &eforecoi$$ing $o lifelong $hyroid horone

re1laceen$


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Precocio&s P&berty

Presence of secondary seual develo1en$ &y age@

! in a girl

? in a &oy


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!pproac, to Precocio&s P&berty

o"*h 'o/i*y

Bo#' Ag'

P'ma*&' h'a/h'

*og'#

P'ma*&' A'#a/h'

A#og'#

Noma 6aia#*

Noma

%'#*a

A#og'# *og'#

P'iph'a

Pa*hoogi/a

#/'a'

P'/o/io& P&-'*y


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!pproac, to Precocio&s P&berty: 2emales

P'ma*&'h'a/h'

*og'#

P'ma*&'A'#a/h'

A#og'#

Noma aia#*

Noma

*og'#9 a#og'#

%'#*a

:6ay

A'#a

:*h'

*og'#

:6ay

A'#a

:*h'

A#og'#

P'iph'a

Pa*hoogi/a

#/'a'

Bo#' ag';


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!pproac, to Precocio&s P&berty:

Males

P'ma*&'

A'#a/h'

A#og'#

Noma aia#*

Noma

'*' < 4m

%'#*a

'*'

A'#a

:*h'

A#og'#

'*'

A'#a

:*h'

*og'#

P'iph'a

Pa*hoogi/a

#/'a'

Bo#' ag';


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Delayed P&berty

2&sence of secondary seual develo1en$ &y age@

- in a girl

4 in a &oy


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Cons$i$u$ional Delay

of row$h and Pu&er$y

Hy1o$halaic or

Pi$ui$ary Cause

Cen$ral

Low

onadal (ailure

Peri1heral

High

LH8 (SH

Delayed Pu&er$y

!pproac, to Delayed P&berty


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Delayed P&berty: %n#estigations

row$h records

one age

LH8 (SH

Se horone levels * no$ needed

O$her horones as clinically indica$ed =/48 /SH8 H8

Prolac$in8 Cor$isol>


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Delayed P&berty: Treatment Cons$i$u$ional Delay of row$h and Pu&er$y

oys@ /rea$ if 1sychologically dis$ressed

De1o$ $es$os$erone '*00 g "+ on$hly -

irls@ 9sually donJ$ $rea$ =even low dose es$rogens cause

accelera$ed s#ele$al a$ura$ion>


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Delayed P&berty: Treatment

Hy1er 5 Hy1ogonado$ro1ic Hy1ogonadis

oys@/es$os$erone in$rauscular inec$ion8 $ransderal 1a$ch5gel or

orally8 gradually increasing $o adul$ doses

irls@S$ar$ wi$h low dose es$rogen8 increasing over *, years8 $hen &egin

cycling wi$h es$rogen and 1roges$erone


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(,ort (tat&re


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!pproac, to (,ort (tat&re

o"*h 6'o/i*y

ag'* H'igh*

amiia Sho* S*a*&' %o#*i*&*io#a D'ay

Noma aia#*

U$

Dymophi/ y#om'

%homooma io'

P'#a*a

,'i/a*io#

%ho#i/ i'a'

#o/i#'

Po*#a*a

Popo*io#a*' Dipopo*io#a*'

Pa*hoogi/

Sho* S*a*&'

!diopathic ShortStature


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C,ronic

Disease


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Endocrinopat,y

paediatric endocinology dr sarah lawrence_compressed (1)

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