Endocrine Disorders

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Chapter 33 Endocrine Disorders

Robert E. Sapien, MD, FAAP

1 Why are children susceptible to hypoglycemia? What glucose level is considered hypoglycemia? How do you correct it?

Children are susceptible because:

image Glycogen stores are small.

image Glucose utilization is high because of increased metabolic demands.

image Fewer gluconeogenesis precursors are generated because of less fat and muscle mass.

image A child’s developing brain needs a constant source of substrate.

The level at which to treat is controversial, but most clinicians treat at a level < 60 mg/dL. The treatment for infants is typically at a level < 40 mg/dL. Treat infants with D10W (10% dextrose in water), 2–4 mL/kg body weight; for 1- to 8-year-olds, D25W (25% dextrose in water), 2–4 mL/kg; older children and adolescents, D50W (50% dextrose in water) ampule.

Reid SR, Losek JD: Hypoglycemia in infants and children. Pediatr Emerg Med Rep 5:23–30, 2000.

2 At what point should diagnostic tests for hypoglycemia be obtained? What would they be?

The tests should be obtained at first presentation of the hypoglycemic child to the emergency department (ED) (at triage)—but only if they can be obtained quickly. A bedside glucose test is essential because a delay in treatment can be neurologically devastating. A diagnostic workup is indicated for infants and children in whom the hypoglycemia has no explanation (i.e., oral hypoglycemic ingestion, sepsis, poor intake, anorexia in a diabetic child who received insulin). The tests include plasma glucose, electrolytes, lactate, pyruvate, keto hydroxybutyrate, acetoacetate, insulin, glucagon, cortisol, growth hormone, free fatty acids, alanine, glycerol, and urinalysis, including reducing substances.

KEY POINTS: HYPOGLYCEMIA

1 Rapid identification is essential.

2 Children are susceptible because of small glycogen stores and high glucose utilization.

3 Treat hypoglycemia as follows: for infants (glucose level < 40 mg/dL), D10W, 2–4 mL/kg; for 1- to 8-year-olds (glucose level < 60 mg/dL), D25W, 2–4 mL/kg; for older children and adolescents, D50W ampule.

3 What is the most common cause of hyperthyroidism in children?

Graves’ disease is the most common etiology. Children at risk include females (female to male ratio, 5:1), those with familial autoimmune diseases (e.g., diabetes, adrenal insufficiency), and those from families with a history of thyroid disease.

Sills IN: Hyperthyroidism. Pediatr Rev 15:417–420, 1994.

McKeown NJ, Tews MC, Gossain VV, Shah S: Hyperthyroidism. Emerg Med Clin North Am 23:649–667, 2005.

4 Presenting symptoms of hyperthyroidism are commonly attributed to which other body systems or disorders?

Symptoms from hyperthyroidism are commonly confused with other conditions. For example, cardiac disorders (palpitations, sinus tachycardia) and psychological problems (school difficulties, labile emotions, hyperactivity) mimic hyperthyroidism.

Sills IN: Hyperthyroidism. Pediatr Rev 15:417–420, 1994.

McKeown NJ, Tews MC, Gossain VV, Shah S: Hyperthyroidism. Emerg Med Clin North Am 23:649–667, 2005.

5 What is thyroid storm? What is the treatment?

The symptoms may be nonspecific (fever, tachycardia, agitation, nausea, vomiting), making the diagnosis difficult unless there is a clear hyperthyroid history. The three systems most affected include the cardiovascular, gastrointestinal, and central nervous systems. Supportive care is the first step in management (oxygen, IV fluids, acetaminophen for fever). This should be followed by an IV β-blocker for the cardiac effects, and routine hyperthyroid treatments (propylthiouracil, iodine) in high doses.

Sills IN: Hyperthyroidism. Pediatr Rev 15:417–420, 1994.

McKeown NJ, Tews MC, Gossain VV, Shah S: Hyperthyroidism. Emerg Med Clin North Am 23:649–667, 2005.

6 If congenital hypothyroidism is missed in the neonatal period, when will signs/symptoms present?

Patients will present with symptoms at 6–12 weeks of age. The first signs and symptoms are constipation, a large posterior fontanel, poor feeding, jaundice, and hypothermia.

Fisher DA: Hypothyroidism. Pediatr Rev 15:227–232, 1994.

Foley TP: Hypothyroidism. Pediatr Rev 25:94–99, 2004.

7 How do the adrenal glands respond to stress? What are examples of such body stressors? What do children with adrenal insufficiency and children taking long-term exogenous glucocorticoid therapy have in common?

The adrenal glands respond to stress by secreting increased amounts of glucocorticoids and mineralocorticoids. Physiologic stresses include surgery, trauma, and infection. All of these children require stress dose replacement of glucocorticoids and mineralocorticoids because their adrenal glands cannot respond to such stressors.

Oberlin JM, Rogers WM, Fenton CL: Endocrine emergencies: Recognizing signs and symptoms. Pediatr Ann 34:870–877, 2005.

Spahn JD, Kamada AK: Special considerations in the use of glucocorticoids in children. Pediatr Rev 16:266–272, 1995.

8 What signs and symptoms are likely in children with acute adrenal insufficiency?

Signs and symptoms are due to failure of the adrenals to respond to a stress, and they are fairly nonspecific. They include dehydration with hypovolemic shock, hypoglycemia, hyponatremia, hyperkalemia, fever, abdominal pain, and lethargy.

Kappy MS, Bajaj L: Recognition and treatment of endocrine/metabolic emergencies in children. Part I. Adv Pediatr 49:245–272, 2002.

Oberlin JM, Rogers WM, Fenton CL: Endocrine emergencies: Recognizing signs and symptoms. Pediatr Ann 34:870–877, 2005.

9 What is the emergency treatment for acute adrenal insufficiency?

Much of the initial stabilization is supportive care. The treatment includes:

image Fluid resuscitation with normal saline (500 mL/m2) for shock and dehydration

image Correction of the hypoglycemia with D25W

image Hydrocortisone, 2–3 mg/kg via IV route

image Correction of the hyperkalemia (sodium polystyrene sulfonate, glucose/insulin, calcium gluconate, sodium bicarbonate)

image Monitoring of vital signs, cardiac rhythm, perfusion, glucose, and electrolytes

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