Exam 2 - Growth & Endocrine Flashcards
Normal growth in childhood is _______
5-6.5cm/year
Adult height is _______
Genetically pre-determined.
Breasts (thelarche) -> pubic hair (pubarche usually w/in 1 year of thelarche) -> menarche (begins at stage 4 breast but usually when Mom started hers)
Genetic conditions with growth alterations have specific growth charts.
How to calculate a target or mid-parental height.
Boys: (mom’s height + dad’s height + 13)/2 cm
Girls: (mom’s height + dad’s height -13)/2 cm
If the childs’ growth pattern curve at 20 is within 5cm of mid-parental height = appropriate for family.
Evaluate for abnormal growth patient who are below _____ and above______
3rd and 97th percentile.
Bone age is abnormal if: _____
Advanced or delayed by more than 2 SDs
Basic screening lab test to evaluate abnormal growth in children.
CBC w diff (anemia, infection)
BMP (renal disease, electrolyte abnormalities, DI)
LFT (metabolic or infectious disorders with liver dysfxn)
UA and urine pH (renal tubular acidosis)
ESR (chronic inflammation)
Normal reasons for short stature
Familial
Constitutional growth delay
Pathologic reasons for short stature
Nutritional
Endocrine
Chromosomal
IUGR
Skeletal dysplasia
Chronic illness
Psychosocial
How do you investigate bone age?
AP view of LEFT wrist/hand and look at how fused the growth plates are. This calculates the amount of remaining growth the patient has.
If bone age is < chronological age, then they have ________ time to grow. Ex?
MORE.
Girl age 9 with bone age 8. She might be short now but she has more time to grow.
Delayed bone age with _____ or _______
GH deficiency
Hypothyroidism,
Chronic illness, malnutrition.
Bone age can be advanced with ______
Prolonged elevation of sex steroid levels
Percocious puberty
Congenital adrenal hyperplasia
GNRH agonists
Exogenous sex steroids
Significant: sotos syndrome, beckwith-wiedemann syndrome, Marshall-smith syndrome
Genetic (familial) short stature
Falls off growth chart around 8-19 months then resumes normal velocity
Normal PE
Growth rate >4cm/yr
Bone age is equal to chronological age.
No pubertal delay
No deceleration of weight
Constitutional delay: bone age is ______ and _______ to height age.
Delayed
Approximately equal
Genetic syndromes that can lead to tall stature
Kleinfelter
Marfan
Beckwith-wiedemann
Sotos
Weaver
What is length vs stature/height?
Length - laying down (<2yo)
Stature/height - standing up (>2yo)
Girls pubertal delay?
Boys?
Girls no breast development by 13 years OR no menarche by 3 years after breast development OR no menarche by 16
Boys no testicular enlargement by 14.
Is disconcordant pubertal delay most likely pathologic?
Yes. Some things are growing the way they’re supposed to and others are not.
Learn tanner stages
TQ What is the correct sequence of events in puberty in boys
Growth of testicles
Pubic hair appears
Growth of penis scrotum
Axillary hair
First ejaculations
Growth spurt
Facial hair
Adult height.
TQ What is the correct sequence of events in puberty in girls
Breast bud appearance
Pubic hair
Growth spurt
Axillary hair
Pubic hair matures
Breasts mature
Menarche
Adult height
Review slide 49 causes of delayed puberty
In precocious puberty, bone age is _______
Advanced.
Weed and weight lifting supplements can cause Gynecomastia.
In GH deficiency, growth plates _____
Don’t close or take longer to close. Bone age will be younger so they have much more growth potential
Hypothyroid and bone age - they have more time.
Hyperthyroidism - bone age - they grow tall and skinny but their plates close sooner so they stop growing faster.
Hypothyroidism is diagnosed with ______ TSH and ______ T4
Increased
Low
Look in Harriet lane for synthroid dosing in pediatrics!
Most common manifestation in peds hypothyroid is ::
Growth failure.
Most common phenotypic characteristic associated with Turner’s syndrome?
Short stature.
PTH, VitD, calcium and Mg all go together….
80% of kids with hypercalcemia have ____ or ____
Hyperparathyroidism or malignant tumor.
Review endo slides 106-121
Steroid taper not usually needed for courses less than ______. If longer than that, then taper by ______% every _____
10-14 days
25-50%
2-7days
PKU - no aspartame!
Endocrine disorders typically manifest in 1 of 4 ways?
Excess hormone
Deficient hormone
Abnormal response from end organ
Gland enlargement
______ is most closely associated with postnatal growth in addition to GH
Insulin-like growth factor 1 (IGF-1).
What is the most important factor affecting growth on a world-wide basis?
Nutrition
Pubarche results from. _________ and results in ________
Adrenal maturation
Pubic hair, oiliness of hair, axillary hair, acne, body odor, gonadal sex steroid.
Laurence-Moon-Bardet-Biedl, Prader-Willi and Kallmann syndromes can result in
Hypopituitarism and hypogonadotropic Hypogonadism
What is an organic/environmental cause of gonadotropin fxn?
Intentional caloric restriction or malnutrition resulting in body weight less than 80% ideal weight.
Turner syndrome = ________ failure
Kleinfelter syndrome = ________ failure
Ovarian
Testicular
Most common cause of GnRH-independent precocious puberty (more common in _____) is ________
Some associated features?
Females
McCabe-Albright syndrome.
Precocious gonadarche, bone disorder with polyostotic fibrous dysplasia and cafe-au-lait spots
Short stature not associated with weight gain could be attributed to ———-
Hypothyroid
Congenital adrenal mineralocorticoid deficiency manifests as _______ and _______
Hyponatremia and hyperkalemia by 5-7 DOL
Diagnostic criteria for T1DM
- S/s of diabetes AND a random plasma glucose >200mg/dl
- OR fasting plasma glucose >= 126mg/dl
- OR 2-hr plasma glucose greater than or = to 200mg/dl during an OGTT
- OR hemA1c >= 6.5
In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day.
Wt loss in DM T1 is attributed to:
Fluid loss from osmotic diuresis
Glucose unable to be stored in cells so start burning fat and muscle.
T1DM prevalence 1:300
Peak age at dx: 4-6; 10-14
AGBI - Autoimmune in T1DM destroys. Which cells?
Alpha cells glucagon, Beta cells insulin
Beta cells.
Tzield - what is this?
A medication that could potentially pause the autoimmune destruction of pancreatic beta cells.
Check siblings of patients with T1DM for pancreatic antibodies - potential to give Tzield?
What are some environmental triggers that can provide the “second hit” for development of T1DM?
Viruses: rubella, COVID, others.
Early exposure to cow’s milk and vit D deficiency.
What is the diagnostic criteria for DKA?
BG >200 (D)
+ Ketonemia/ketonuria (K)
PH <7.3 (A)
Bicarb <20 or anion gap >12 are used for severity rating
T/F: all patients with DKA come in with some cerebral edema
True. Treatment is so important because it can exacerbate and worsen, but they come in with cerebral edema already there.
Lipolysis and proteolysis - how do these contribute to patho of DKA?
Lipolysis - ketone bodies
Proteolysis - converts amino acids into sugars which worsens hyperglycemias.
3 pronged approach to successfully navigating DKA?
Fluids
Insulin
Electrolytes
What is the fluid resuscitation considerations for DKA?
Large fluid shifts can be a concerning risk factor for cerebral edema BUT
Treat shock - 20cc/kg bolus over first 1-2 hours is still okay! You can do 10cc, however 20-30 is standard.
Start insulin drip at:
0.05 - 0.1 u/kg/hr
What is a goal for dropping blood glucose?
Drop by 50-100mg/dl/hr
Target range of 200-300 while correcting acidosis
T/F: in DKA, once blood sugar reaches goal, you can stop the insulin.
FALSE: continue the dextrose and IV insulin until ACIDOSIS is corrected, then wean off insulin drip.
Electrolytes - which ones are usually deficient in DKA and need to be replaced?
Na, K. Usually just add to IVF, don’t’ usually need bolusing.
How to recognize cerebral edema
Sudden, persistent drop in HR, change in LOC, HA, emesis, incontinence, unexplained tachypnea
Insulin total daily requirement is 0.5-1u/kg/day up to 1.5u/kg/day during ______
Puberty - raises requirements.
Partial coverage can be an issue in teenage years - they know that if they don’t cover their carbs all the way, then they’ll pee it out and they won’t gain the weight. It’s an eating disorder.
What is an ESSENTIAL accompanying referral for new T1DM dx
MENTAL HEALTH!
Basal rate is _______% of TDD which is _____
T/F: the bolus amount makes up the other 50%
50%
0.5-1u/kg/day
FALSE! The bolus is related to meal/snack/carb consumption
I:C ratio
450/TDD
What is this?
Amount of carbs 1 unit of insulin will cover.
Ex: 30kg kid has a 30u/day TDD
450/30 = 15. 1u of insulin will cover 15 carbs.
Correction factor rule
1800/TDD - the amount of mg/dl we estimate 1 unit of insulin will lower blood glucose.
1800/30 = 60mg/dl 1 unit will lower BG
If BG is 220, then 1u will lower to 160.
Target blood glucose for bolus calculations?
150mg/dl
When can hypoglycemia occur after exercise?
During, immediately after or 8-24hrs later. BS usually decreases during exercise but MAY initially increase.
Do not exercise if _______ are present.
Ketones.
Usually need ____ g carbs for every _____ mins of vigorous exercise.
15
30
Hypoglycemia is _____ in kids
Rule of 15s. Give 15g carbs and recheck in 15 mins.
<70mg/dl
Test blood sugar every _______ on sick days and check ______
2-4hrs
Urine ketones.
What is the “honeymoon” T1DM?
May last for weeks - 1 year or longer.
Once glucotoxicity is resolved, the pancreas starts functioning (partially) again. They may need less insulin, maybe even off of bolus insulin all together! BUT it is NOT a cure. It is just temporary. Once beta cells are fully destroyed, their insulin requirement will increase again.
T1DM associated autoimmune disease?
HyPOthyroid is most common but hyper is common too
HgA1c goal for children?
<7%
