Endocrinology

Question 1

Define obesity in childhood

Answer 1

Obesity is defined when the BMI is >95th percentile for age and sex

Question 2

Discuss the etiology of obesity in childhood

Answer 2

Lifestyle:
- dietary: overeating, infant feeding practices, foods provided
- physical inactivity
- Social behaviours: restricted eating or binge eating
Perinatal factors:
- low or high birth weight
- maternal smoking or diabetes
Neurologic:
- Hypothalmic
- hypopituitarism
- depression
Endocrine:
- Polycystic ovarian syndrome
- hypogonadism
- growth hormone deficiency 
Iatrogenic:
- medication: antipsychotics, glucorticoids
Genetic:
- M4CR defect leading to lepton defiance
- Prader-Willi Syndrome

Question 3

List some of the complications of obesity

Answer 3

Metabolic: 
- increase risk of metabolic syndrome -> diabetes, hyperlipidemia, hypertension, abdominal obesity
Cardiovascular: 
- increased risk of atherosclerosis and cardiovascular disease
Respiratory: 
- obstructive sleep apnea
GI: 
- GERD
- NAFLD
Gynaecology: 
- PCOS
MSK: 
- pain
- SCFE
Neurological: 
- idiopathic intracranial hypertension

Question 4

List some important tests when evaluating a child with obesity

Answer 4

Growth: height, weight, BMI
Bloodwork: fasting glucose, HbA1c, LFT, lipid profile
Sleep study

Question 5

Discuss the management of obesity

Answer 5

5A’s
Ask: ask for permission to discuss weight
Assess: determine the patients risks and drivers for obesity (4Ms)
- Mental: anxiety (social), depression, eating disorder
- Mechanical: GERD, sleep apnea, MSK pain
- Metabolic: T2DM, HTN, Dyslipidemia
- Milieu: Bullying/stigma, family stressors, school attendance, relationships
Advise: discuss risks of obesity and possible benefits of change to lifestyle
- healthy sleep patterns
- health eating behaviour
- increase in physical activity
- manage psychological disorders
Agree: set realistic and attainable goals regarding improving lifestyle, not weight goal
Assist: provide support

Question 6

Discuss the pathophysiology of type 1 diabetes

Answer 6

Have autoimmune destruction of the beta islet cells of the pancreas -> loss of insulin production -> hyperglycaemia, ketone bodies, low energy state

Question 7

Discuss the presentation and management of Type 1 diabetes

Answer 7

Presentation: 3P’s -> polyuria, polydipsia, polyphagia and weight loss and fatigue
Diagnosis:
- fasting blood glucose >7
- HbA1c >=6.5%
- 2 hour post glucose tolerance test >=11
- abnormal lab values and symptoms or abnormal values at two different times with no symptoms
- presentation with DKA
Management:
- q4h insulin measurements
- basal-bolus insulin regimen

Question 8

Discuss the insulin targets for children

Answer 8

Younger kids have greater risk of CNS damage with hypoglycaemia so have higher plasma glucose targets
<6 HbA1c <8% or plasma 6-10
6-12 HbA1c <7.5% or plasma 4-10
>13 HbA1c <7% or plasma 4-7

Question 9

List some of the complications of poor glucose control

Answer 9

Retinopathy: nonproliferative (microaneurysms, macular edema, hard exudates) and proliferative (neovascularization, vitreous hemorrhage, retinal detachment)
Nephropathy: glomerulosclerosis, basement membrane thickening
Neuropathy: peripheral polyneuropathy due to demyelination, autonomic neuropathy (incomplete bladder emptying, sexual dysfunction, gastroperesis), diabetic ulcer (motor, sensory and autonomic changes)
Cardiovascular disease: increase risk of artherosclerosis

Question 10

Discuss when patient should go to ICU with DKA

Answer 10

PICU:

• pH <7.1
• age <2
• hypotension
• suspected cerebral edema

Question 11

Discuss the risk factors for cerebral edema

Answer 11

Clinical: 
- new onset diabetes
- age <5
- severe dehydration
Lab: 
- pH <7.1
- high urea
- initial Na >145mmol/L 

Presentation: headache, nausea/vomiting, decreased level of consciousness