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Paediatrics > Metabolic, Endocrine & Growth > Flashcards

Metabolic, Endocrine & Growth Flashcards

1
Q

DKA presentation in children:

A
  • acetone breath smell
  • vomiting, dehydration
  • abdo pain
  • hyperventilation Kussmaul breathing (due to acidosis_
  • hypovolaemic shock, drowsiness, coma, death
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2
Q

What are crucial investigations in a child presenting with DKA, name 5+

A
  • 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)
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3
Q

What level is blood glucose and blood ketones over in DKA?

A
  • BM >11.1mmol/L

- Ketones >3.0mmol/L

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4
Q

Why is U&Es checked in a child with DKA?

A

-check for dehydration level/severity and hypokalaemia

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5
Q

What are the 4 key parts of the management of DKA?

A
  • fluids
  • insulin
  • potassium
  • identify/treat underlying cause and re-establish oral fluids, diet and sc insulin
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6
Q

How to approach fluid resus in a child with DKA?

  • for first 12hrs : __% __ with __mmol KCl
  • add _% ___ when BM is
A
  • 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
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7
Q

Once fluid resus has began in treating a DKA, what is it important to monitor?

A
  • fluid input and output
  • BM and ketones (hrly)
  • U&Es, creatinine and acid-base status
  • neurological state
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8
Q

If there is vomiting or decreased consciousness in a child presenting with DKA what do you need for acute gastric dilatation?

A

an NG tube

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9
Q

If a child with DKA is shocked or in coma, they should be transferred to __ and should have a ___ and a ___ ______ inserted.

A

PICU

  • central venous line
  • catheter
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10
Q

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
A
  • 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

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11
Q

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.

A
  • high
  • cells in exchange for H+
  • fall following treatment with insulin
  • start as soon as maintenance fluids started
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12
Q

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..?

A

-keep the infusion going until 1hr after the subcut insulin has been given

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13
Q

What changes to white cell count can be seen in DKA?

A

Neutrophilia

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14
Q

type 1 DM=beta cells destroyed autoimmune, type II most obesity related.. name 3 other types/causes of diabetes:

A
  • 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)
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15
Q

What are 3 markers of beta cell destruction in type 1 DM?

A
  • glutaminic acid decarboxylase antibodies
  • islet cell antibodies
  • insulin antibodies
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16
Q

What are the classic triad of signs of diabetes? Additionally what ay children develop secondarily at night?

A
  • polydipsia
  • polyuria
  • weight loss
  • nocturnal enuresis (loss of bladder control)
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17
Q

What ddx may hyperventilation of DKA or it’s abdo pain be mistaken for? Why is urgent recognition of DKA important?

A
  • pneumonia or appendicitis or constipation can be misdiagnosed in DKA
  • high risk of mortality in children untreated
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18
Q

What is threshold for type 1 diabetes diagnosis?

A
  • raised random glucose >11.1mmol/L
  • glycosuria
  • ketosis
  • (fasting BM >7mmol/L
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19
Q

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)

A
  • this velvety dark skin on the neck or armpits

- is a sign of insulin resistance

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20
Q
  • children presenting with type 1DM need to be educated on what?
    e. g. sickday rules in ketoacidosis
A
  • basic understanding of DM pathophys
  • injection of insulin technique
  • finger-prick monitoring
  • healthy diet
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21
Q

Name an example of short acting soluble human regular insulin, given 15-30mins before meals.

A
  • actrapid

- humulin S

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22
Q

Insulatard and Humulin I are what type of insulin? Peaks 4-12hrs, onset 1-2hrs

A

-intermediate acting insulin

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23
Q

Name 2 ways of giving insulin.

A
  • continuous infusion from a pump or by injections

- pen-like devices with insulin containing cartridges

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24
Q

The injection sites of the insulin are cycled to avoid ____

A

lipohypertrophy

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25
Q

How should insulin be injected?

A

-skin pitched up and insulin injected at 45degrees

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26
Q

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

A
  • cont. subcut insulin pump

- ‘basal bolus’

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27
Q

What level do families aim for BMs before meals?

A

4-7mmol/L

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28
Q

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 __

A

Carbohydrate

  • carbohydrate counting
  • premeal BMs
  • post-meal exercise pattern
29
Q

Name 5 factors that increase blood sugar levels:

A
  • inadequate insulin, food
  • illness, stress
  • menstruation
  • GH, Corticosteroids
  • sex hormones @puberty
30
Q

Name 3 factors that decrease blood glucose e.g. insulin,

A
  • exercise
  • alcohol
  • marked anxiety/excitement
  • hot weather
  • some drugs
31
Q

HbA1c should be checked at least x__ per year as a guide to overall DM control over the last __ weeks

A

x4per year

6-12weeks

32
Q

What is the HbA1c target?

A

<48 (6.5%)

33
Q

Hypoglycaemia symptoms often develop with BM < __

-symptoms vary between children but typically..

A

<4mmol/L

  • hunger, tummyache, sweatyness
  • dizzy/wobbly on legs
34
Q

Hypos in young children may be detected by ___

A
  • pallor and irritability

- if in doubt check BM

35
Q

How can a hypo be treated at an early stage?

A
  • glucose tablets
  • a sugary drink
  • oral glucose gel if child is unable to cooperate
36
Q

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?

A
  • IM glucagon injection

- food e.g. biscuit/sandwich to prevent BMs dropping again

37
Q

How is hypo in a T1 DM unconscious child brought into hospital treated?

A

-with IV glucose

38
Q

name 3 macro and 3 micro-vascular complications of T1DM long-term:

A

MACRO: HT, coronary artery disease, cerebrovascular disease
MICRO: retinopathy, nephropathy, neuropathy

39
Q

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 __.

A
  • increase
  • reduced food intake
  • regular BM monitoring
  • ketones (if BM and ketones increasing, urgent rapid acting insulin or medical help is necessary)
40
Q

Name some areas of T1DM control and care that the child’s school will be involved/trained in:

A
  • dietary needs
  • what to do in hypo/loss of consciousness
  • support in taking BMs
  • calculating and giving pre-lunch insulin injection/bolus from pump
41
Q

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
…

A
  • 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?
42
Q

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

A
  • 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
43
Q

What 2 diseases are screened for at diagnosis for a child with T1DM?

A
  • coeliac disease at diagnosis, test again if symptomatic

- thyroid disease at diagnosis and screen annually

44
Q

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?

A
  • up to 1.0 then 2.0units/kg/day

- Growth Hormone, oestrogen, testosterone

45
Q

What is the threshold used for diagnosis of hypoglycaemia?

A

<2.6mmol/L

46
Q

What are 3 clinical features of hypoglycaemia

A
  • sweating
  • pallor
  • CNS signs: irritable, headache, seizure, coma
47
Q

If hypoglycaemia persists, e.g. neonatal hypoglycaemia, the neurological sequalae can be permanent..what may these include?

A
  • epilepsy
  • severe learning difficulties
  • microcephaly
48
Q

In what cases of a sick child should a blood glucose always be checked? (!) DEFG-don’t ever forget glucose!

A
  • septic/seriously ill
  • has a prolonged seizure
  • develops an altered state of consciousness
49
Q

Name 3 causes of hypoglycaemia that arise due to an insulin excess?

A
  • excess exogenous insulin
  • bets cell tumours/disorders e.g. insulinoma
  • drug induced e.g. sulfonylureas
  • autoimmune (insulin receptor antibodies)
  • Beckwith syndrome
50
Q

Name 3 causes of hypoglycaemia that arise without hyperinsulinaemia?

A
  • 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
51
Q

Name 3 reactive aka non-fasting causes of hypoglycaemia?

A
  • galactosaemia
  • leucine sensitivity
  • fructose intolerance
  • maternal DM
  • hormonal deficiency
  • aspirin/alcohol poisoning
52
Q

When does ketotic hypoglycaemia arise?

NB: the child is often ___ and insulin levels are ___

A
  • in young children following a short period of starvation (poss due to limited gluconeogenesis reserves)
  • child is thin, insulin reserves are low
53
Q

In a child with ketotic hypoglycaemia, what helps to prevent episodes of hypoglycaemia, and what happens with the condition in later life usually?

A
  • regular snacks, extra glucose drinks when ill

- resolves spontaneously

54
Q

In a child with hypoglycaemia in childhood and hepatomegaly, what may it suggest about the cause of the hypoglycaemias (which can be profound)?

A

-inherited glycogen storage disorder

55
Q

recurrent, severe neonatal hypoglycaemia may be caused by persistent ____ _______ of infacy

A

-persistent hypoglycaemic hyperinsulinism of infancy

56
Q

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.

A
  • gene mutations
  • insulin release
  • non-ketotic
57
Q

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?

A
  • high conc glucose solutions

- diazoxide

58
Q

If correcting hypoglycaemia with an IV infusion, what is the maximum boluses that can be delivered?
-__ml/kg of _% bolus followed by _% glucose infusion.

A

-5ml/kg of 10% bolus followed by 10% infusion

59
Q

What is the risk of aggressively correcting hypoglycaemia with excess volume of a hypertonic solution?

A

-cerebral oedema

60
Q

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?

A

-IM glucagon

NB: corticosteroids may be needed if the cause may be pituitary or adrenal dysfunction related

61
Q

Menarche occurs ~2.5yrs after start of puberty, in terms of further growth what does this indicate?

A
  • growth is coming to an end

- only about 5cm growth remaining

62
Q

What is the fist clinical sign of puberty in males and how is it measured?

A
  • testicular enlargement (>4mL volume)

- measured with orchidometer

63
Q

What is the first sign of female puberty?

A

-palpable breast bud

64
Q

Suggest 3 causes of congenital hypothyroidism:

A
  • mal-descent of thyroid and athyrosis
  • dyshormonogenesis
  • iodine deficiency
  • hypothyroidism secondary to TSH deficiency
65
Q

What is mal-descent of the thyroid (most common cause of sporadic congenital hypothyroidism)

A
66
Q

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?

A
  • faltering growth, delated development
  • feeding problems
  • prolonged jaundice
  • constipation
  • pale, cold, mottled, dry skin
  • coarse facies
  • large tongue
  • hoarse cry
  • umbilical hernia
67
Q

Acquired hypothyroidism is more common in females, give 5 symptoms of how it can present (similar to adult acquired+ growth affected)

A
  • 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
68
Q

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?

A
  • on routine neonatal biochemical screening (Guthrie test) identifying a raised TSH in the blood
  • except 2ndry to pituitary abnormalities will not be picked up
69
Q

Treatment for congenital hypothyroidism is started by 3 weeks of age to reduce risk of what?

A

-reduce risk of impaired neurodevelopment

Paediatrics (12 decks)

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