Nursing Care of a Family

When a Child has an

Endocrine Disorder
SHIRLEY LIM-SOTTO, MD, FPPS
Diabetes Insipidus Hyperthyroidism

Congenital Diabetes Mellitus

Hypothyroidism
DIABETES INSIPIDUS

Diabetes insipidus is a disease in which there is decreased release of ADH by the

pituitary gland.

This causes less reabsorption of fluid in the kidney tubules.

Urine becomes extremely diluted, and a great deal of fluid is lost from the body.

Diabetes insipidus may reflect an X-linked dominant trait, or it may be transmitted by an

autosomal recessive gene.

It may also result from a lesion, tumor, or injury to the posterior pituitary, or it may

have an unknown cause.

Assessment
The child experiences excessive thirst ( polydipsia ) that is relieved only by drinking large

amounts of water; there is accompanying polyuria.

The specific gravity of the urine will be as low as 1.001 to 1.005 (normal values are more

often 1.010 to 1.030).

Urine output may reach 4 to 10 L in a 24-hour period (normal range, 1 to 2 L)

DIABETES INSIPIDUS

Assessment
Because so much fluid is lost, sodium becomes concentrated or hypernatremia occurs

with gradual symptoms of irritability, weakness, lethargy, fever, headache, and seizures.

Polyuria appear as bed-wetting in a toilet-trained child or weight loss because of the

large loss of fluid.

If the condition remains untreated, the child is in danger of losing such a large quantity

of water that dehydration and death can result.

MRI or CT scanning of the skull reveals whether a lesion or tumor is present.

Therapeutic Management
Surgery is the treatment of choice if a tumor is present.

If the cause is idiopathic, the condition can be controlled by the administration of

desmopressin (DDAVP), an arginine vasopressin.

Caution children that they will notice an increasing urine output just before the next

dose is due so they can arrange their day according to where bathrooms are located.
 CONGENITAL HYPOTHYROIDISM
Thyroid hypofunction causes reduced production of both T 4 and T 3 .

This occurs as a result of an absent or nonfunctioning thyroid gland in a newborn

This may not be noticeable at birth because the mother’s thyroid hormones maintain adequate

levels in the fetus during pregnancy.

The symptoms of the disorder become apparent during the first 3 months of life in a

formula-fed infant and at about 6 months in a breastfed infant.

Because congenital hypothyroidism leads to both severe, progressive physical and cognitive

challenges, early diagnosis is crucial.

Assessment
Newborn screening will detect congenital hypothyroidism and is mandatory at birth

If an infant should miss this, an early sign that parents report is that their child sleeps

excessively, but because the tongue is enlarged, they notice respiratory difficulty, noisy

respirations, or obstruction.

+ poor suck

The skin of the extremities usually feels cold, dry, scaly, and the child does not perspire.

Pulse, respiratory rate, and body temperature all become subnormal.

Prolonged jaundice occurs due to the immature liver’s inability to conjugate bilirubin.

Anemia may increase the child’s lethargy and fatigue.

 CONGENITAL HYPOTHYROIDISM

Assessment
On PE, the hair is brittle and dry, and the child’s neck appears short and thick.

The facial expression is dull and open mouthed because of the infant’s attempts to

breathe around the enlarged tongue.

The extremities appear short and fat; as muscles become hypotonic, deep tendon

reflexes decrease and the infant develops a floppy, rag-doll appearance.

Generalized obesity usually occurs.

Dentition will be delayed, or teeth may be defective when they do erupt.

The hypotonia affects the GIT as well, so the infant develops chronic constipation; the

abdomen enlarges because of intestinal distention and poor muscle tone.

Many infants have an umbilical hernia.

Lab Findings:

Infants have low radioactive iodine uptake levels, low serum T 4 and T 3 levels, and

elevated thyroid-stimulating factor.

Blood lipids are increased.

An X-ray may reveal delayed bone growth.

An ultrasound reveals a small or absent thyroid gland.

 CONGENITAL HYPOTHYROIDISM

Therapeutic Management
Transient hypothyroidism usually fades by 3 months’ time.

The treatment for true hypothyroidism is the oral administration of synthetic thyroid

hormone (sodium levothyroxine).

The child needs to continue taking the synthetic thyroid hormone indefinitely to

supplement that which the thyroid does not make.

Supplemental vitamin D may also be given to prevent the development of rickets when,

with the administration of thyroid hormone, rapid bone growth begins.

Further cognitive challenges can be prevented as soon as therapy is started, but any

degree of impairment that was already present cannot be reversed, making the disorder

one of the most preventable causes of mental development delay known.

Periodic monitoring of T 4 and T 3 helps to ensure an appropriate medication dosage.

If the dose of thyroid hormone is not adequate, the T 4 level will remain low and

there will be few signs of clinical improvement.

If the dose is too high, the T 4 level will rise and the child will show signs of

hyperthyroidism: irritability; fever; rapid pulse; and perhaps vomiting, diarrhea, and

weight loss
 CONGENITAL HYPOTHYROIDISM

Untreated, the condition will result in severe irreversible cognitive deterioration or delay.
 HYPERTHYROIDISM

Hyperthyroidism is oversecretion of thyroid hormones by the thyroid gland.

Neonatal Graves disease develops in the newborns of 1% to 2% of pregnant women who

have the disease.

Like transient hypothyroidism, this usually resolves between 3 to 12 weeks of age with no

long-term results as the maternal antibodies are cleared.

In older children, overactivity of the thyroid gland can occur from the glands being

overstimulated by TSH from the pituitary gland due to a pituitary tumor.

More frequently, however, hyperthyroidism in children is caused by an autoimmune

reaction that results in overproduction of immunoglobulin G (IgG), which stimulates the

thyroid gland to overproduce T4 .

Assessment
Some children may have a genetic predisposition to development of the disorder,

although Graves disease often follows a viral illness or a period of stress.

With overproduction of T 3 and T 4 , children gradually experience nervousness, tremors,

loss of muscle strength, and easy fatigue.

Their basal metabolic rate, blood pressure, and pulse all increase.
 HYPERTHYROIDISM
Assessment
They always feel hungry and, although they eat constantly, do not gain weight and may

even lose weight because of the increased basal metabolic rate.

On X-ray, bone age will appear advanced beyond the chronologic age of the child

Unless the condition is treated, the child is not likely to reach usual adult height because

epiphyseal lines of long bones will close before full height can be attained.

On PE:

The thyroid gland, which usually is not prominent in children, appears as a swelling on

the anterior neck as goiter develops.

In a few children, the eye globes become prominent (exophthalmia), giving the child

a wide-eyed, staring appearance.

Laboratory tests show:

elevated T4 and T3 levels and increased radioactive iodine uptake.

TSH is low or absent because the thyroid is being stimulated by antibodies, not by

the pituitary gland.

Ultrasound will reveal the enlarged thyroid.

 HYPERTHYROIDISM

Therapeutic Management
Therapy consists first of a course of a β-adrenergic blocking agent, such as propranolol,
to decrease the antibody response.

After this, the child is placed on an antithyroid drug, such as propylthiouracil (PTU) or

methimazole (Tapazole), to suppress the formation of T4.

While the child is taking these drugs, the blood is monitored for leukopenia

(decreased white blood cell count) and thrombocytopenia (decreased platelet

count)—side effects of these drugs.

If either of these results, the drug is discontinued until the WBC or platelet count

returns to normal, so the child does not develop an infection or experience

spontaneous bleeding.

The child needs to continue to take the drug for 2 to 3 years before the condition

“burns itself out.”

The exophthalmos may not recede, but it will not become worse once therapy is

instituted.
HYPERTHYROIDISM

Therapeutic Management
If the child has a toxic reaction to medical

management (severely lowered WBC or platelet

count) or is noncompliant about taking the

medicine, radioiodine ablative therapy with Iodide

or thyroid surgery to reduce the size of the thyroid

gland can be accomplished.

This has long-term effects: supplemental

thyroid hormone therapy may need to be

taken indefinitely because the gland is no

longer able to produce an adequate amount

of thyroid hormone.

It is important that adolescent girls be

carefully regulated before they consider

childbearing because hyperthyroidism during

pregnancy can lead to neonatal

hyperthyroidism in a fetus.
 HYPERTHYROIDISM

NURSING DX OUTCOME EVALUATION

Situational low self-esteem related to lack Child states positive traits about self and

of coordination and presence of prominent identifies friends and activities enjoyed; is not

goiter or exophthalmia the victim of bullying because of unusual

appearance

Hyperthyroidism begins gradually and so may be late before it is detected.

S/Sx in puberty : losing weight, behavior problems in school, which occur because

of the hand or tongue tremors that make it hard for them to write or speak and the

nervousness that makes them unable to sit still during class.

Caution children not to stop taking the medicine abruptly, or a thyroxine crisis

(sudden onset of extreme symptoms of hyperthyroidism) can occur.

Help parents understand that surgery may not dispel the need for medication; if a

large portion of the thyroid gland is removed, it may be necessary for their child to

take medicine indefinitely to make up for the missing gland.

In any event, it is preferable to try a course of medical management before

resorting to surgery
 TYPE 1 DIABETES MELLITUS

Type 1 diabetes mellitus is a disorder that involves an absolute or relative deficiency of

insulin, which is in contrast to type 2, where insulin production is only reduced.

Type 1 diabetes is equal in incidence in boys and girls and affects approximately 1 of

every 500 children and adolescents in the United States

ETIOLOGY:
The disease apparently results from immunologic damage to islet cells in susceptible

individuals.

Why autoimmune destruction of islet cells occurs is unknown, but children with the

disorder have a high frequency of certain human leukocyte antigens (HLAs),

particularly HLA-DR3 and HLA-DR4, located on chromosome 6, that may lead to

susceptibility.

If one child in a family has diabetes, the chance that a sibling will also develop the

illness is higher than in other families because siblings also tend to have one of the

specific HLA that are associated with the disease.

 TYPE 1 DIABETES MELLITUS
DISEASE PROCESS
Insulin can be thought of as a compound that opens the doors to body cells, allowing

them to admit glucose, which is needed for functioning.

If glucose is unable to enter body cells because of a lack of insulin, it builds up in the

bloodstream ( hyperglycemia ).

As soon as the kidneys detect hyperglycemia ( > 160 mg/dl), the kidneys attempt to

lower it to normal levels by excreting excess glucose into the urine, causing

glycosuria, accompanied by a large loss of body fluid (polyuria).

Excess fluid loss, in turn, triggers the thirst response (polydipsia),

producing the three cardinal symptoms of diabetes; polyuria, polydipsia, and

hyperglycemia.

Because body cells are unable to use glucose but still need a source of energy, the body

begins to break down protein and fat.

If large amounts of fat are metabolized this way, weight loss occurs and ketone

bodies, the acid end product of fat breakdown, begin to accumulate in the

bloodstream (creating high serum cholesterol levels and ketoacidosis) and spill into

the urine as ketones.

 TYPE 1 DIABETES MELLITUS
ASSESSMENT
Although children may be prediabetic for some time, the onset of symptoms in childhood

is usually abrupt.

Parents notice increased thirst and increased urination.

The dehydration may cause constipation.

Laboratory Studies

Laboratory studies usually show a random plasma glucose > 200 mg/dl (normal

range, 70 to 110 mg/dl fasting; 90 to 180 mg/dl not fasting) and significant

glycosuria

A diagnosis of diabetes is established if one of the following three criteria is present

on two separate occasions:

Symptoms of diabetes plus RBS >200 mg/dl

An FBS > 126 mg/dl

A 2-hour plasma glucose level > 200 mg/dl during a 75-g oral glucose

tolerance test (OGTT)

ASSESSMENT
Laboratory Studies

If diabetes is detected, the diagnostic workup also usually include glycosylated

hemoglobin (HbA1c) evaluation.

Normally, the hemoglobin in red blood cells carry only a trace of glucose. If serum

glucose is excessive, however, excess glucose attaches itself to hemoglobin

molecules, creating HbA1c.

In nondiabetic children, the usual HbA1c value is 1.8 to 4.0.

A value > 6.0 reflects an excessive level of serum glucose.

Measuring HbA1c has advantages because it provides information on what the

serum glucose levels have been during the preceding 3 to 4 months.

THERAPEUTIC MANAGEMENT
Therapy for children with type 1 diabetes involves five measures:

insulin administration

regulation of nutrition and exercise

stress management

blood glucose monitoring

urine ketone monitoring

The standard of care in the US regarding a child with newly diagnosed diabetes involves

a hospital admission of approximately 3 days, which includes extensive education

involving caretakers and the child.

THERAPEUTIC MANAGEMENT
When children are first diagnosed with diabetes, they are usually hyperglycemic and

perhaps ketoacidotic.

To correct the metabolic imbalance, they are given insulin administered IV at a dose

of 0.1 to 0.2 units/kg/hr.

The insulin given for emergency replacement this way is regular (short-acting) insulin

such as Humulin-R because this is the form that takes effect most quickly.

Insulin is always injected SC except in emergencies, when half the dose is given IV.

Subcutaneous tissue injection sites used most frequently in children include those of

the upper outer arms and the outer aspects of the thigh

Absorption is increased if the muscles under the injection site are exercised, so it is

best to choose sites that will not be exercised soon after the injection

In the hospital, record the injection site in the child’s record or nursing plan, so each

nurse can check it before an injection and not repeat an injection site.

if the same injection site is used repeatedly, a great deal of subcutaneous atrophy

(lipodystrophy) can occur, causing deep pockmarks

Although parents should keep additional bottles of insulin in the refrigerator to increase

shelf life, insulin should be administered at room temperature because this diminishes

subcutaneous atrophy and ensures peak effectiveness

THERAPEUTIC MANAGEMENT

An overall meal pattern should include three spaced meals that are high in fiber plus a

snack in the midmorning, midafternoon, and evening to keep carbohydrate amounts as

level as possible during the day.

Whenever children with diabetes undergo a stressful situation, either emotionally or

physically, they may need increased insulin to maintain glucose homeostasis.

Urine testing is not used routinely but is used to test for ketonuria if the child develops

abdominal pain or diarrhea and is not able to eat. Ketones revealed by a test strip

(urinalysis ) is a sign fat is being used for energy or that the child is becoming acidotic

Children as young as early school age can learn the techniques of finger puncture and

reading a computerized monitor.

But they are usually adolescents before they can be counted on to independently

monitor their serum glucose levels on a daily basis.

Nursing Diagnoses
& Related
Interventions for
Type I Diabetes
 #1 NURSING DX OUTCOME EVALUATION

Health-seeking behaviors related to Child demonstrates insulin injection

self-administration of insulin, technique to nurse, describes steps

balanced exercise, and nutrition correctly, and discusses plans for an

exercise and nutrition program

1. Self-administration of insulin From 8yo, children can be taught to administer their own insulin

2. Exercise

This is important because it uses up carbohydrates and helps reduce hyperglycemia.

No type of exercise is restricted for children with diabetes.

A problem that arises with vigorous exercise, however, is the development of hypoglycemia

due to increased use of glucose by active body cells.

One way to minimize this effect is to choose injection site that is least likely to be exercised.

Another method is to eat additional carbohydrates or decrease the regular insulin injection

according to an established protocol before exercise

3. Hygiene
children should be taught to cut their toenails straight across, to prevent ingrown toenails

tend to cuts and scrapes promptly so that healing can begin right away

Girls may need to be reminded of good perineal care to prevent vaginal infections.
 #2 NURSING DX OUTCOME EVALUATION

Parental anxiety related to newly Parents accurately describe their child’s

diagnosed diabetes mellitus in their child illness and treatment and ways in which

the disease will affect their lifestyle.

They state a specific plan for daily routine

child care and identify potential problems

in the schedule and ways they can be

managed

1. Be certain they have the telephone number of the healthcare facility, liaison, or home

care person to call during the first days of home management so they have someone to

consult before they give insulin the first several times.

2. Children with diabetes need follow ups every 3 months.

3. Teach Hypoglycemic Management.

An episode of hypoglycemia is an extremely serious condition and must be

prevented, if possible, because it can lead to coma and seizures.

Severe glucose depletion can lead to permanent brain damage with mental

and motor impairment because brain cells need glucose for metabolism
cont... 3. Teach Hypoglycemic Management.
Symptoms of hypoglycemia occur when the blood glucose level falls to 60 mg/dl.

It results from the administration of too much insulin, excessive exercise (because exercise

uses up glucose), or failure to eat enough food.

Typically, beginning symptoms include nervousness, weakness, dizziness, sweating, or tremors.

In many children, the first signs of hypoglycemia are behavior problems: temper tantrums,

stubbornness, silliness, irritability, or simply “not acting like usual self.

When the signs of hypoglycemia are recognized, a child needs an immediate source of

carbohydrates.

Fifteen grams of a fast-acting carbohydrate such as that contained in a half glass of

orange juice or regular soda is recommended.

It is easy for children to carry glucose tablets or hard candy for these times.

If there is no improvement in symptoms and the blood glucose level has not risen by 15

mg/dl after 15 minutes, more carbohydrates should be given.

If the child is comatose when first discovered or is too upset or uncooperative to take oral

sugar, parents can inject a specified dose of glucagon hydrochloride IM. This converts the

glycogen that is stored in the liver into glucose. After waking up, an oral form of glucose can

be given.
cont... 3. Teach Hypoglycemic Management.
If parents cannot give their child an injection and oral sugar cannot be given, honey,

corn syrup, cake icing gel, or glucose can be rubbed onto the gums or inside the cheek.

As soon as children are out of the coma or are cooperative, they should take a source of

complex carbohydrates, such as crackers or whole wheat toast, to prevent further

hypoglycemia.

If children are going to engage in an active sport, such as swimming, tennis, or

basketball, they should ingest a source of sugar before participation.

This precaution is extremely important before swimming because a child who

suddenly becomes weak in the middle of a pool may be unable to reach the side

safely

Occasionally, insulin overuse and persistent hypoglycemia cause a rebound

hyperglycemic response; this is referred to as the Somogyi phenomenon.

This phenomenon is suspected when children have nighttime (2AM or 3AM)

hypoglycemia followed by high early-morning hyperglycemia.

These children need to be referred to their healthcare provider because they

actually need less insulin rather than more to correct the problem
cont... 4. Teach Signs of Ketoacidosis
Because hyperglycemia leads to diabetic ketoacidosis (DKA) which is a metabolic

emergency.

DKA is a serious complication of diabetes that occurs when the body produces high

levels of blood acids called ketones. The condition develops when the body can’t

produce enough insulin and begins to break down fat as fuel.

It may be difficult to distinguish between hypo and hyperglycemia because

hyperglycemia presents with almost the same symptoms as hypoglycemia: irritability,

vomiting and abdominal pain, and behavior changes such as temper tantrums.

If a parent does not know which is the problem, the child should be offered a

carbohydrate, as if the problem were hypoglycemia.

The added carbohydrate will do no harm if the problem is already

hyperglycemia, whereas giving insulin is harmful if the cause is hypoglycemia.

An inability to void is a good clue that it is hypoglycemia because with

hyperglycemia, urine output is copious—one of the primary signs of diabetes.

The real key to differentiating DKA from hypoglycemia is the blood glucose level.
cont... 4. Teach Signs of Ketoacidosis
If ketoacidosis is not relieved when it

first begins, it becomes severe with

deep and rapid respirations (Kussmaul

breathing) as the body attempts to

“blow off” carbon dioxide and lessen

the acidotic state.

The child’s breath smells sweet

because of the presence of ketone

bodies, and the pulse rate may be

rapid.

Signs of dehydration, including dry

mucous membranes and skin, sunken

eyeballs, and no tears, may be

present.

DKA is typically the picture when

children are first diagnosed as having

diabetes
 TYPE 2 DIABETES MELLITUS ( T2D )

characterized by diminished insulin secretion, is a separate disease from type 1 diabetes

because it is not caused by autoimmune factors.

Usually, children with T2D do not need daily insulin because their disease can be

managed with diet alone or with diet and an oral hypoglycemic agent.

Once thought to occur only in older adults, T2D is now seen as early as in overweight

school-aged children. Other influencing factors are

a strong family history of diabetes;

children from African, Hispanic, Asian, or Native Indian descent;

diet high in fats and carbohydrates; and

those who do not exercise regularly

Polycystic ovary syndrome (PCOS) is also strongly associated with the disorder.

Symptoms often become apparent for the first time at puberty because increasing sex

hormones naturally increase insulin resistance, creating a need for more insulin

production.
 TYPE 2 DIABETES MELLITUS ( T2D )

Children’s urine will show glucose but few ketones.

About 90% will have dark shiny patches on the skin ( acanthosis nigricans ) most often

found between the fingers and between the toes, on the back of the neck (“dirty

neck”), and in axillary creases.

Children whose family has a history of T2D, or have symptoms such as acanthosis

nigricans or high blood pressure should be screened by FBS at puberty and every 2yrs

Therapy consists of nutrition and exercise, the same as for type 1 diabetes, combined

with an oral antiglycemic agent such as a biguanide (metformin)

T2D is a chronic condition that will extend into adulthood and be present for life.

In order to prevent complications, children need good instruction in how to manage

their illness.
THANK YOU
FOR YOUR
ATTENTION!