Dr. Clark-8 questions. High Yield 70% Diabetes Mellitus Type I Diabetes Control & Complications Trial (DCCT) -proved blood glucose needs to be managed …
Dr Clark-8 questions
High Yield 70
Diabetes Mellitus Type I
Peak onset Adolescence @ onset of puberty
10-15yo
Immune Marker -Islet cell cytoplasmic antibodies ICAs
-may be present 10 years b4 insulin
deficit noticed
Etiology -viral infection
-chromosome 6: HLA D3, HLA D4 gene loci
common
-exposure to cows milk
Management -Blood sugars are NOT controlled, they
are managed
-Diabetes Control Complications
Trial DCCT
-proved blood glucose needs to
be managed
cant be over managed
60 reduction in
complications
-otherwise end organ damage is
out of control
-9 yr study
-A carb is a carb is a carb
-it doesnt matter what it starts
as, everything gets
converted to glucose fat,
protein, CHO
-high fiber slows the absorption of
glucose
-Match the insulin regimen to the
patients lifestyle:
-dose has to be varied
-pattern adjusted as needed
-kids have to have insulin after meals to
guarantee glucose is there
-others take insulin just b4 meals
-Exercise is very important
-maintains lean body mass
- body fat
-maintains sensitivity to insulin
-no sports activity is
CONTRAindicated
Hypoglycemia
-blood sugar70
-treatment:
-dep on symptoms
-Mild: pt will drink juice or soda
-Moderate:
-may need help drinking juice b/c
confused, out of
character bhvr
-Severe
-canunconsciousness
-life threatening if not treated
immediately
-needs help managing
-Glucagon 1mg IM
Diabetic Ketoacidosis
-life threatening medical emergency
-treatment:
1-Fluid therapy : most important
-expands ECF 09 saline to begin
with
-follow initial infusion w/ 045
saline
-to
maintain electrolytes
-hypokalemia may last for days
so give KCl
2-Insluin Therapy: 1unit
Ivpush/followed by 01 unit/kg/hr drip
-this rate lowers blood glucose
100mg/hr
shouldnt drop faster than
this
3-Sodium Bicarb therapy
-rarely done, and if do it, do it
SLOWLY
-NEVER give IV push
-pitfalls of therapy:
1-Too much fluid too fast
osmolarity of blood, while brain
osmolarity was
maintained so fluid sucked into
brain thru BBBcerebral
edema
2-Too rapid drop in glucose
cerebral edema
3-Not enough K
hypokalemiaheart stops
4-Too much HCO3 too fast
blood pH rises, but brain pH
becomes more acidic
cerebral edemacoma worsens
When is treatment in the
Pediatric ICU indicated? 1-Children 5yo younger w/ CO2
levels10-15mEg/L
2-Any unstable child
3-Any child with CNS abnormalities
4-Any child who has experienced a pitfall
of treatment
5-Any child not responding to treatment
as expected
6-if Dr does not feel qualified
7-younger children regardless of nursing
staff
-bottom line: the dr needs to be
qualified to treat the kid
so send to PICU
-Note: older children can be treated in
adult ICU if nurses have
had pediatric training feel
comfortable w/ kid
Thyroid Disorders in Kids
What is the primary screening test
For thyroid fx in kids? TSH
Other thyroid tests T4: worthless
Free T FT4:
-of no use in a healthy person
-may help ID what thyroid is doing
if it is malfunctioning
Congenital hypothyroidism -What is the incidence of
congenital hypothyroidism?
1 in 4000
-untreatedcretinism:
-mental retardation
-growth supression
-TSH surge
-normal consequence of birth
helps baby adapt to life
outside uterus
-returns to normal in about a week
-most newborns with
hypothyroidism
present NORMAL
-in other words, there is no
clinical sign they of
hypothyroidism
-therefore thyroid screening is
essential
-neglecting this is Felony
offense by law
-treatment:
-begin: 0-3months @ 10-
15mcg/kg/day
-then individualize the dose
-dont over treat
-etiology: thyroid dysgenesis most common
80
Hyperthyroidism -Graves disease
-kids DONt get the EXOPHTHALMOS
if they get it at all, it is
much more mild than adult
-Symptoms:
-emotional lability: sobbing
-fatigue exhaustion on exertion
but
-figity lack of concentration
when sitting
-PE
-most have small goiter but not
always
-tremor
-Treatment
1-PTU
-b/c cant tell which
will/wont respond
2-Radioiodine therapy
-if PTU didnt work
Neonatal Graves Disease -rare
-transplacentally acquired TSIs
-antibodies cross placenta
stimulate babys thyroid
-transient, but severe in first 2-3
weeks of life
-babys thyroid hormone concentration is
NOT independent of moms:
-2/3 of babys thyroid hormones in
utero are from mom
-if treat mom, youre treating
baby too
-however, baby does have an
independently functioning
hypothalamic adrenal axis, its
just not sufficient to take
care of baby on its own so moms
hormones support it
-symptoms
-irritability
-primnent, sweaty eyes
-Treatment:
1-Lugols highly concentrated
iodine solution
-immediately inhibits I-uptake
due to Wolf-Chaikoff
effect
decreased thyroid hormone
output
2-PTU
-takes 5 days to work b/c mech
is on organification
Growth Puberty
How can you estimate
Growth potential in a child? -estimate the maturation of the
child
-Girls: Fathers ht in cm
Mothers ht in cm-13
2
-Boys: Fathers ht in cm
Mothers ht in cm 13
2
Secondary growth disturbance -treat underlying abnormality kid
will grow just fine
Constitutional growth delay -nothing abnormal
-kid ends up catching upnormal ht
Growth Hormone deficiency tx:
-hGH all is recombinant DNA
Puberty in Girls -growth spurt happens EARLY in puberty
-@ onset of breast development
-complete by menarche
-increased LH FSH
-8-13yo
-1st sign of puberty:
breast development
-Breast Tanner Stages
1-prepubertal
2-breast bud
3-enlargement of breast areola; no
seprtn of contours
4-areola papilla project above
contour of breast
5-mature breast
-areola breast in same plane
-papilla erect
-Pubic Hair Tanner Stages
1-no pubic hair
2-some long pigmented hair
3-dark course curled hair
4-abundant adult type hair @ mons
veneris only
5-adult escachon pattern to medial
thighs inverse
triangle
-21-hydroxylase deficiency
-salt losing
-ambiguoius genitalia
-VIRILIZATION
-17OH progesterone elevated
Puberty in Boys -growth spurt happens LATE in puberty
-increased LH FSH
-11-14yo
-first sign: enlargement of the testes
-order of hair presentation:
1-pubic
2-axillary
3-facial
-Genital Tanner Stages
1-prepubertal
2-Enlargement of testes scrotum
-scrotal skin thining first
3-Penis lengthens
Testes scrotum enlarge
4-Penis width length increases
Testes scrotum enlarge
Scrotum pigmentation
5-Adult size shape of penis
testes
Lack of adult pubic hair
escachon
-Pubic Hair Tanner Stages
1-4: same as females
5-adult escachon to linea alba
-21-hydroxylase deficiency
-precocious puberty
Ambiguous Genitalia
What do you say to parents
Of a newborn baby with
Ambiguous genitalia? I dont know
What 3 things determine 1-chromosomes
Normal sexual differentiation 2-hormones
Of a baby? 3-ability of tissues to respond to
hormones
all 3 required: not just chromosomes
SRY -sex determining region of the Y
chromosome
-if blocked, will develop as
female by
default
Wolfian ducts -stabilized by testosterone
-secrete mullarian inhibitory factor
Hydrospadius -the mot common anatomical
abnormality not hormonal
-req surgical correction
New Rules to gender
Assignment 1-delay until preference of child can be
considered
2-XY males w/ small penis may be better
off raised male
3-psychological adjustment may not be
satisfactory, even if parents
are comfortable w/ gender assignment
Source:shawtracking.com
