Metabolic, Endocrine & Growth Flashcards
DKA presentation in children:
- acetone breath smell
- vomiting, dehydration
- abdo pain
- hyperventilation Kussmaul breathing (due to acidosis_
- hypovolaemic shock, drowsiness, coma, death
What are crucial investigations in a child presenting with DKA, name 5+
- blood glucose
- blood ketones
- U&Es, creatinine
- ABG/VBG
- blood/urine culture (look for infective trigger)
- ECG monitoring for hypoK+ T-wave changes
- weight (compare to recent clinic level for dehydration level)
What level is blood glucose and blood ketones over in DKA?
- BM >11.1mmol/L
- Ketones >3.0mmol/L
Why is U&Es checked in a child with DKA?
-check for dehydration level/severity and hypokalaemia
What are the 4 key parts of the management of DKA?
- fluids
- insulin
- potassium
- identify/treat underlying cause and re-establish oral fluids, diet and sc insulin
How to approach fluid resus in a child with DKA?
- for first 12hrs : __% __ with __mmol KCl
- add _% ___ when BM is
- for first 12hrs : 0.9% saline with 40mmol KCl
- add 5% glucose when BM is <14mmol/L
- after 12hrs: if plasma Na+ stable, give 0.45% saline/5% glucose with 40mmol KCl
Once fluid resus has began in treating a DKA, what is it important to monitor?
- fluid input and output
- BM and ketones (hrly)
- U&Es, creatinine and acid-base status
- neurological state
If there is vomiting or decreased consciousness in a child presenting with DKA what do you need for acute gastric dilatation?
an NG tube
If a child with DKA is shocked or in coma, they should be transferred to __ and should have a ___ and a ___ ______ inserted.
PICU
- central venous line
- catheter
How do you approach giving insulin in the treatment of DKA?
- infusion (not bolus): ___units/kg/hr IV, monitor ___
- change to a solution containing __%___ when BM is
- infusion (not bolus): 0.1 units/kg/hr IV, monitor hourly
- change to a solution containing 5% glucose when BM is <14 mmol/L to avoid hypoglycaemia
In a patient with DKA the potassium will be ___ due to the displacement from __ in exchange for __, it will __ following treatment with ___. So start potassium replacement as soon as _____ ___ are started.
- high
- cells in exchange for H+
- fall following treatment with insulin
- start as soon as maintenance fluids started
In a child with DKA treated with insulin infusion, who is starting subcut insulin to re-establish this, what do you do in terms of stopping the infusion..?
-keep the infusion going until 1hr after the subcut insulin has been given
What changes to white cell count can be seen in DKA?
Neutrophilia
type 1 DM=beta cells destroyed autoimmune, type II most obesity related.. name 3 other types/causes of diabetes:
- maturity onset diabetes of the young (genetic beta cell defects)
- neonatal diabetes (defective beta cell function)
- gestational diabetes
- genetic syndromes (downs, turners)
- drugs (steroids)
- pancreatic insufficiency (e.g. iron overload in thalassaemia)
What are 3 markers of beta cell destruction in type 1 DM?
- glutaminic acid decarboxylase antibodies
- islet cell antibodies
- insulin antibodies
What are the classic triad of signs of diabetes? Additionally what ay children develop secondarily at night?
- polydipsia
- polyuria
- weight loss
- nocturnal enuresis (loss of bladder control)
What ddx may hyperventilation of DKA or it’s abdo pain be mistaken for? Why is urgent recognition of DKA important?
- pneumonia or appendicitis or constipation can be misdiagnosed in DKA
- high risk of mortality in children untreated
What is threshold for type 1 diabetes diagnosis?
- raised random glucose >11.1mmol/L
- glycosuria
- ketosis
- (fasting BM >7mmol/L
In children with type 2 DM, what is acathosis nigricans a sign of? (skin tags, or PCOS in teenage girls is a sign of the same thing)
- this velvety dark skin on the neck or armpits
- is a sign of insulin resistance
- children presenting with type 1DM need to be educated on what?
e. g. sickday rules in ketoacidosis
- basic understanding of DM pathophys
- injection of insulin technique
- finger-prick monitoring
- healthy diet
Name an example of short acting soluble human regular insulin, given 15-30mins before meals.
- actrapid
- humulin S
Insulatard and Humulin I are what type of insulin? Peaks 4-12hrs, onset 1-2hrs
-intermediate acting insulin
Name 2 ways of giving insulin.
- continuous infusion from a pump or by injections
- pen-like devices with insulin containing cartridges
The injection sites of the insulin are cycled to avoid ____
lipohypertrophy
How should insulin be injected?
-skin pitched up and insulin injected at 45degrees
Most children are started on a continuous _ _ __ __ or a multiple daily injection regimen(‘__ __’) with rapid acting insulin before each meal and a long-acting insulin in the late evening
- cont. subcut insulin pump
- ‘basal bolus’
What level do families aim for BMs before meals?
4-7mmol/L
Insulin doses need to match __ intake. “__ counting” allows pts to calculate their insulin requirements for the meal taking into account their pre-meal __ and post-meal __
Carbohydrate
- carbohydrate counting
- premeal BMs
- post-meal exercise pattern
Name 5 factors that increase blood sugar levels:
- inadequate insulin, food
- illness, stress
- menstruation
- GH, Corticosteroids
- sex hormones @puberty
Name 3 factors that decrease blood glucose e.g. insulin,
- exercise
- alcohol
- marked anxiety/excitement
- hot weather
- some drugs
HbA1c should be checked at least x__ per year as a guide to overall DM control over the last __ weeks
x4per year
6-12weeks
What is the HbA1c target?
<48 (6.5%)
Hypoglycaemia symptoms often develop with BM < __
-symptoms vary between children but typically..
<4mmol/L
- hunger, tummyache, sweatyness
- dizzy/wobbly on legs
Hypos in young children may be detected by ___
- pallor and irritability
- if in doubt check BM
How can a hypo be treated at an early stage?
- glucose tablets
- a sugary drink
- oral glucose gel if child is unable to cooperate
What should teachers and parents be trained to administer in the case of a child having a severe hypo with reduced conciousness? Following admistration what should be given, why?
- IM glucagon injection
- food e.g. biscuit/sandwich to prevent BMs dropping again
How is hypo in a T1 DM unconscious child brought into hospital treated?
-with IV glucose
name 3 macro and 3 micro-vascular complications of T1DM long-term:
MACRO: HT, coronary artery disease, cerebrovascular disease
MICRO: retinopathy, nephropathy, neuropathy
Infections usually cause insulin requirements to ____. However the dose needed is very variable, party due to reduced __ ___. So give dose according to regular ___. During illness blood should also be tested for __.
- increase
- reduced food intake
- regular BM monitoring
- ketones (if BM and ketones increasing, urgent rapid acting insulin or medical help is necessary)
Name some areas of T1DM control and care that the child’s school will be involved/trained in:
- dietary needs
- what to do in hypo/loss of consciousness
- support in taking BMs
- calculating and giving pre-lunch insulin injection/bolus from pump
In a regular assessment for a child with T1DM, suggest some (4+) routine things that are checked in on?
e.g. review diary of BMs, responses to them etc
-diet
…
- any hypos, DKA or hospital admissions
- is there still awareness of hypos
- absence from school/interference w life/support
- HbA1c <48mmmol/L?
- is insulin regime appropriate/optimal
- lipohypertrophy/lipoatrophy at injection sites?
Based on complications of T1DM long-term, what things will be checked in a child presenting for a periodic general review?
-e.g. reminder for annual flu vaccination
- growth/pubertal development/avoiding obesity
- BP check for HT yearly
- screen for microalbuminuria annually from 12yrs
- check pulses and sensation (assess circulation)
- retinal photography annually from 12yrs
- feet check annually
What 2 diseases are screened for at diagnosis for a child with T1DM?
- coeliac disease at diagnosis, test again if symptomatic
- thyroid disease at diagnosis and screen annually
If in early childhood insulin requirement are approx 0.5units/kg per day, what do they increase up to in adolescence? This is because some hormones antagonise insulin, which 3 in particular?
- up to 1.0 then 2.0units/kg/day
- Growth Hormone, oestrogen, testosterone
What is the threshold used for diagnosis of hypoglycaemia?
<2.6mmol/L
What are 3 clinical features of hypoglycaemia
- sweating
- pallor
- CNS signs: irritable, headache, seizure, coma
If hypoglycaemia persists, e.g. neonatal hypoglycaemia, the neurological sequalae can be permanent..what may these include?
- epilepsy
- severe learning difficulties
- microcephaly
In what cases of a sick child should a blood glucose always be checked? (!) DEFG-don’t ever forget glucose!
- septic/seriously ill
- has a prolonged seizure
- develops an altered state of consciousness
Name 3 causes of hypoglycaemia that arise due to an insulin excess?
- excess exogenous insulin
- bets cell tumours/disorders e.g. insulinoma
- drug induced e.g. sulfonylureas
- autoimmune (insulin receptor antibodies)
- Beckwith syndrome
Name 3 causes of hypoglycaemia that arise without hyperinsulinaemia?
- liver disease
- ketotic hypoglycaemia of childhood
- inborn errors of metabolism e.g. glycogen storage disorders
- hormonal deficiency e.g. low GH/ACTH, Addison’s. CAH
Name 3 reactive aka non-fasting causes of hypoglycaemia?
- galactosaemia
- leucine sensitivity
- fructose intolerance
- maternal DM
- hormonal deficiency
- aspirin/alcohol poisoning
When does ketotic hypoglycaemia arise?
NB: the child is often ___ and insulin levels are ___
- in young children following a short period of starvation (poss due to limited gluconeogenesis reserves)
- child is thin, insulin reserves are low
In a child with ketotic hypoglycaemia, what helps to prevent episodes of hypoglycaemia, and what happens with the condition in later life usually?
- regular snacks, extra glucose drinks when ill
- resolves spontaneously
In a child with hypoglycaemia in childhood and hepatomegaly, what may it suggest about the cause of the hypoglycaemias (which can be profound)?
-inherited glycogen storage disorder
recurrent, severe neonatal hypoglycaemia may be caused by persistent ____ _______ of infacy
-persistent hypoglycaemic hyperinsulinism of infancy
persistent hypoglycaemic hyperinsulinism of infancy is a rare disorder caused by ___ ____ of various pathways leading to dysregulation of ___ release by islet cells leading to profound non-____ hypoglycaemia.
- gene mutations
- insulin release
- non-ketotic
What is the treatment for persistent hypoglycaemic hyperinsulinism of infancy initially to maintain safe BMs before PET scans may reveal localised pancreas lesions that can be resected?
- high conc glucose solutions
- diazoxide
If correcting hypoglycaemia with an IV infusion, what is the maximum boluses that can be delivered?
-__ml/kg of _% bolus followed by _% glucose infusion.
-5ml/kg of 10% bolus followed by 10% infusion
What is the risk of aggressively correcting hypoglycaemia with excess volume of a hypertonic solution?
-cerebral oedema
If there is a delay in giving infusion/failure to respond to glucose in the treatment of a severe hypo or if access cannot be obtained, what is the next step?
-IM glucagon
NB: corticosteroids may be needed if the cause may be pituitary or adrenal dysfunction related
Menarche occurs ~2.5yrs after start of puberty, in terms of further growth what does this indicate?
- growth is coming to an end
- only about 5cm growth remaining
What is the fist clinical sign of puberty in males and how is it measured?
- testicular enlargement (>4mL volume)
- measured with orchidometer
What is the first sign of female puberty?
-palpable breast bud
Suggest 3 causes of congenital hypothyroidism:
- mal-descent of thyroid and athyrosis
- dyshormonogenesis
- iodine deficiency
- hypothyroidism secondary to TSH deficiency
What is mal-descent of the thyroid (most common cause of sporadic congenital hypothyroidism)
Congenital hypothyroidism is more often asymptomatic and picked up on screening, but possible symptoms may include (5)
Clue: think about effects on growth, skin, bowel, face, tongue, cry, hernias?
- faltering growth, delated development
- feeding problems
- prolonged jaundice
- constipation
- pale, cold, mottled, dry skin
- coarse facies
- large tongue
- hoarse cry
- umbilical hernia
Acquired hypothyroidism is more common in females, give 5 symptoms of how it can present (similar to adult acquired+ growth affected)
- short stature, poor growth, learning difficulties
- delayed puberty, amenorrhoea, obesity
- cold intolerance, -cool peripheries,
- dry skin, -thin, dry hair
- bradycardia
- pale, puffy eyes, loss of eyebrows
- goitre
- constipation
- poor concentration, deterioration in school work
- slipped upper femoral epiphysis
How are most infants with congenital hypothyroidism detected? Hypothyroidism related to what dysfunction will not be picked up on this test due to TSH being low?
- on routine neonatal biochemical screening (Guthrie test) identifying a raised TSH in the blood
- except 2ndry to pituitary abnormalities will not be picked up
Treatment for congenital hypothyroidism is started by 3 weeks of age to reduce risk of what?
-reduce risk of impaired neurodevelopment
