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Child health > Endocrinology - hypoglycaemia/growth > Flashcards

Endocrinology - hypoglycaemia/growth Flashcards

1
Q

Diagnostic criteria of hypoglycaemia

A

plasma glucose < 2.2-2.6mmol/L

Clinical features:
sweating
pallor
CNS (irritability, headache, seizures, coma)

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2
Q

Long-term complications from hypoglycaemia?

A

If it persists:

Epilepsy
Severe learning difficulties
Microcephaly

This risk is greatest in early childhood

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3
Q

Endocrine causes of hypoglycaemia

A 
Hyperinsulinism
Hypopituitarism
Growth hormone insufficiency
Hypothyroidism
Congenital adrenal hyperplasia
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4
Q

Metabolic causes of hypoglycaemia

A 
Glycogen storage disease
Galactosaemia
Organic acidaemia
Carnitine deficiency
Acyl-coA dehydrogenase deficiency
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5
Q

Toxic causes of hypoglycaemia

A

Salicylates
Alcohol
Insulin
Valproate

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6
Q

Hepatic causes of hypoglycaemia

A

Hepatitis
Cirrhosis
Reye syndrome

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7
Q

Systemic causes of hypoglycaemia

A

Starvation even after 4 hrs (infants have high energy requirements and poor reserves of glucose)

Malnutrition
Sepsis
Malabsorption

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8
Q

Which children should have their blood glucose measured?

A

Septicaemia
Appears seriously ill
Has prolonged seizure
Develops and altered state of consciousness

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9
Q

What is ketotic hypoglycaemia

A

In young children

Hypoglycaemia after a short period of starvation - child often short. Resolves in later life

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10
Q

Age group of endocrine and metabolic disorders leading to hypoglycaemia

A

Any age

Hepatomegaly may suggest inherited storage disorder

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11
Q

Epidemiology and nature of recurrent hypoglycaemia caused by PHHI

A

Infancy (rare)

Persistent hypoglycaemic hyperinsulinism of infancy

Gene mutation

Treat with high concentration dextrose solutions and diazoxide to maintain safe levels while investigating:

40% there is a localized lesion in the pancreas amenable to partial resection.
Majority require long-term meds or total pancreatectomy

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12
Q

Transient neonatal hypoglycaemia

A

In neonates

Possibly due to exposure of high levels of insulin in utero if mothers are diabetic or glucose intolerant

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13
Q

investigatons for hypoglycaemia

A

laboratory blood glucose to confirm.

U and Es
LFTs
Osmolality
Blood gas

Test for:
Growth hormone
IGF-1
Cortisol
Insulin
C-peptide
Fatty acids
Ketones
Glycerol
Lactate
Pyruvate
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14
Q

Treatment of hypoglycaemia

A

IV infusion of glucose:
2ml/kg of 10% dextrose bolus followed by infusion

CAREFUL to avoid excess - the hypertonic solution can cause CEREBRAL OEDEMA

If delay in establishing infusion OR failure to respond:
IM glucagon (0.5-1mg)

In a neonate, if the 10% dextrose has not worked, cause is likely to be HYPERINSULINAEMIA

If hypopituitarism or hypoadrenalism is suspected, corticosteroids

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15
Q

Epidemiology of insulin dependent diabetes mellitus (IDDM)

A

Steadily increasing in children.
Now 1 in 500 by 16yrs.

Almost all cases are T1DM.
Some severely obese have T2DM

Risk is 1/40 if father is affected. 1/80 if mother

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16
Q

Associated problems with IDDM

A 
Few weeks of:
Polyuria
Excessive thirst
Weight loss
Nocturnal enuresis - young children

Enuresis
Skin sepsis
Candida infections

17
Q

Education programme in T1DM covers

A 
Basic understanding
Injection techniques
Diet
Adjustment of insulin for sickness or exercise
Blood glucose check
Recognize hypoglycaemia
Where to get help
Support groups and psychological support
18
Q

How can insulin be administered. Correct technique

A

Infusion
Pump
Injection (SC in upper arm, anterior thigh, buttocks, abdomen)

Pinch the skin and insert needle at 45° to avoid complications such as lipohypertrophy.
Rotate sites frequently

19
Q

Insulin administration in infants

A

Insulin pump or 3-4 times/day injection regimen

Short-acting insulin before snacks and a long acting insulin in the evening

20
Q

What are normally the requirements of insulin in children?

A

0.5-1U/kg usually

Can increase to >2U/kg/day in puberty

21
Q

Dietary advice in IDDM

A

Match to insulin regimen
Aim to maintain control while getting good growth

High complex carbohydrates are recommended
Low fat content (<30% of calories)

High in fibres
Avoid foods that cause rapid sugar highs

22
Q

Different types of insulin

A

Rapid acting - short duration
Short acting - onset 30-60 minutes and peak at 2-4hrs (duration 8hrs). Give 15 min before meal.

Intermediate acting - onset after 1-2 hrs and peak at 4-12 hrs

A lot of preparations have predetermined preparations of short and intermediate acting insulin

23
Q

Blood glucose monitoring in IDDM

A

Aim is to keep blood glucose at 4-6mmol/L.
In practice more like 4-10 in children
-to avoid hypoglycaemia!

HbA1c for long-term control over 6-12 weeks - at least x3 per year. Keep below 7.5% (<58mmol/L)

24
Q

What to do if start getting symptoms of hypoglycaemia?

A

Try a sugary drink/snack. Then give a complex carbohydrate to maintain control

Otherwise IM glucagon

25
Q

Why does the level of insulin needed rise in adolescence?

A

Antagonism by GH, oestrogen and testosterone

26
Q

Appreciate that IDDM needs MDT

A

Same as any long-term condition (GP, paediatric consultant, dietician etc)

Specialist Diabetic nurse

27
Q

What are the difficulties in diabetic control in children

A

Eating too many sweets at parties
Infrequent or unreliable blood glucose monitoring
Illness - influences appetite and insulin (dose needs titrating)

Exercise - prolonged exercies requires decrease in insulin

Eating disorders
Family disturbances (eg. divorce)
Poor motivation and support

28
Q

Long-term complications of IDDM (and prevention)

A

Growth and pubertal development - there may be delay/obesity

Check yearly for HTN

Renal disease (screen yearly for microalbuminuria)

Eyes - retinopathy rare in children but should be checked 5 years after diagnosis

Feet - encourage good care and avoid tight shoes or infections by treating early

29
Q

Which diseases are commonly associated with T1DM and should not be missed

A

Coeliac disease
Thyroid disease

Other autoimmune disorders

Low threshhold for investigating

30
Q

Clinical features of DKA

A 
Smell of acetone on breath
Vomiting
Dehydration
Abdo pain
Hyperventilation due to acidosis
Hypovolaemic shock
Drowsiness
Coma and death
31
Q

6 stages of DKA treatment

A
  1. Fluids
  2. Insulin
  3. Potassium
  4. Acidosis
  5. Re-establish oral fluids, subcutanoeus insulin and diet
  6. Identification and treatment of underlying cause
32
Q

Managing fluids in DKA (1.)

A

If shock - resuscitate with normal saline. Rehydrate over 48-72h to avoid cerebral oedema.

Monitor:
Fluid input and output
Electrolytes, creatinine and acid-base status regularly.
Neurological state.

Insert central venous line and urinary catheter if shocked.
NG tube is passed for acute gastric dilatation if there is vomiting

33
Q

The role of insulin in DKA management (2.)

A

Insulin infusion (0.5-1 U/kg per h).
Titrate dose according to blood glucose.
No bolus.
Aim for gradual reduction of blood glucose by 2mmol/h. (faster is dangerous).

Change to 4% dextrose/0.18% saline after 24h (should be <14mmol/L) to prevent hypoglycaemia.

34
Q

The role of Potassium in DKA management (3.)

A

High initially. Will fall after treatment is initiated.
Replacement must be instituted as soon as urine is passed.

Continuous cardiac monitoring and regular plasma potassium measurement until stable

35
Q

The role of acidosis in DKA management (4)

A

Metablic acidosis is present, but do not use bicarbonate unless there is shock or no response to therapy.

Acidosis will self-correct with fluid and insulin.
Monitor capillary ketones.

36
Q

When can iv insulin be stopped in DKA?

A

1 hour after successful SC insulin has been given

37
Q

What can precipitate ketoacidosis?

A

intercurrent infection

Antibiotics may be indicated

Child health (51 decks)

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