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Course: Pediatric Nursing

Topic: Nursing Care of Child with

Endocrine Disorders Part II

The Nurses International Community

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Module Goals

Learners will be able to:

Define hypothyroidism, hyperthyroidism, and diabetes mellitus.
Identify clinical manifestations of above endocrine disorders in children.
Describe related diagnostic procedures.
Explain evidence-based management of the above disorders in children.
Discuss nursing management of a child with above endocrine disorders.

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Hypothyroidism in Children

Condition where thyroid hormone production is not equivalent to the body’s needs.
Hypothyroidism may lead to stunted growth, intellectual disability.
Congenital hypothyroidism

Present at birth
Absent or underdeveloped thyroid gland, or developed gland but unable to produce thyroid hormone.

Acquired hypothyroidism

Thyroid gland function is normal in newborn, but stops functioning well later in the childhood.

John Hopkins Medicine, n.d.

National Institute of Diabetes and Digestive and Kidney Diseases, 2021a

American Thyroid Association, n.d.a

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Hypothyroidism in Children: Causes

Causes of congenital hypothyroidism

Genetic mutations, may be inherited
Maternal iodine deficiency
Placental transfer of antibodies, goitrogens, antithyroid drugs, etc.

Causes of acquired hypothyroidism

Autoimmune thyroiditis (most common cause in United States)
Iodine deficiency (most common cause worldwide)
Radiation therapy to head, neck
Drugs like antiepileptic drugs, lithium, amiodarone, tyrosine kinase inhibitors.

Calabria, 2020

MedlinePlus, 2015

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Hypothyroidism in Children: Signs/Symptoms

In younger children

Less active, sleep more
Feeding difficulty, constipation
Prolonged jaundice
Poor growth

In older children and adolescents

Lack of energy
Increased sensitivity to cold
Dry skin, brittle hair
Puffy and swollen face
Goiter (enlarged thyroid gland)
Weight gain
Impaired school performance
Depression
Delayed puberty

American Thyroid Association, n.d.; MedlinePlus, 2015

Lucile Packard Children’s Hospital Stanford, n.d.

Foley, Sather, & Hurd, n.d.

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Hypothyroidism in Children:

Assessment and Diagnostics

Routine newborn screen test for thyroid hormones after 48 hours of birth but before 4 days of age.
Medical health history and physical exam
Serum thyroid-stimulating hormone (TSH)

Most sensitive test for hypothyroidism diagnosis
High TSH level indicates hypothyroidism

Free serum thyroxine (T4)

Low T4 level is expected in hypothyroidism.

Thyroid autoantibodies test for autoimmune thyroiditis.
Imaging of thyroid, pituitary/hypothalamus area.

National Institute of Diabetes and Digestive and Kidney Diseases, 2021a

American Thyroid Association, n.d.

Shanholtz, 2013

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Hypothyroidism in Children: Management

Newborn screening showing abnormal thyroid levels, should have hormone tests repeated promptly for confirmation and early management
Thyroid hormone replacement therapy initiated soon after diagnosis to protect brain development
Levothyroxine, a thyroid hormone medicine is prescribed once daily

Dose dependent on the level of serum TSH
Blood tests required to adjust dose to identify therapeutic level

National Institute of Diabetes and Digestive and Kidney Diseases, 2021a

American Thyroid Association, n.d.

Shanholtz, 2013

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Nursing Consideration for Child with Hypothyroidism

Ensure newborn is screened for hypothyroidism where possible
Perform thorough assessment of children for hypothyroidism
Quick referral of suspected cases for early management
Obtain medication history of the child to prevent negative drug interactions
Child/parent education:

Taking medication same time everyday, at least 30 minutes prior to meal
Take medication as directed for appropriate dose adjustment, complication prevention
Consult doctor before administering any other medications

National Institute of Diabetes and Digestive and Kidney Diseases, 2021a

American Thyroid Association, n.d.

Shanholtz, 2013

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Critical Thinking Question

Which of the following statements are true regarding hypothyroidism in children? (Select all that apply)

Child has higher level of thyroid stimulating hormone
Normal level of free serum thyroxine differs with age
Hypothyroidism affects child’ school performance
Child should be monitored for weight gain
Thyroid hormone replacement therapy is administered until the child stops growing

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Hyperthyroidism in Children

Overactive thyroid that produces excessive thyroid hormone exceeding body’s need
Too much thyroid hormone speeds up most functions of the body
Grave’s disease is the most common cause
Risk factors:

Diabetes
Thyroiditis
Autonomously functioning thyroid nodule
Medicines containing iodine like amiodarone
Noncancerous tumor of the pituitary gland
Mother with Grave’s disease during pregnancy

American Thyroid Association, n.d.b.

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

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Hyperthyroidism in Children: Complications

Severe complication: Thyroid storm

Extreme tachycardia, hyperthermia, hypertension, congestive heart failure, and delirium, with progression to coma and death

Other complications

Irregular heartbeat that can lead to blood clots, stroke, heart failure, and other heart-related problems
Eye disease called Graves’ ophthalmopathy
Thinning bones, osteoporosis and muscle problems
Menstrual cycle and fertility issues

Calabria, 2020b

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

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Hyperthyroidism in Children: Sign/Symptoms

Hyperthyroidism in Children: Diagnostics

Weight loss despite an increased appetite
Rapid or irregular heartbeat
Nervousness, irritability, trouble sleeping, fatigue

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

Calabria, 2020b

Medical history and physical exam
Blood tests: low TSH level, increased T4 and T3 (triiodothyronine), thyrotropin receptor antibody, thyroid stimulating antibody
Thyroid ultrasonography, or radionuclide scanning to identify etiology

Shaky hands, muscle weakness
Sweating, trouble tolerating heat
Frequent bowel movements
Enlargement in the neck (Goiter)

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Hyperthyroidism in Children: Management

Symptomatic treatment:

Beta-blockers for management of tremors, rapid heartbeat, and nervousness until other drugs are effective.
Antithyroid drugs (ATD) to normalize thyroid hormone level.

Not effective for thyroiditis

Definitive treatment:

Radioactive iodine (RAI)

Slowly destroys thyroid gland cells to reduce thyroid hormone.
Hypothyroidism in almost all cases post-treatment.

Treated with thyroid hormone replacement.

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

Padda & Nguyen, 2021

American Thyroid Association, n.d.b

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Hyperthyroidism in Children: Management (Continued)

Contraindications for RAI:

Under 5-10 years of age
Active thyroid-associated eye disease
Pregnant mothers
Severe hyperthyroidism
Diarrhea, vomiting

Surgical removal of part or most of the thyroid gland

General anesthesia may cause thyroid storm—a sudden, severe worsening of symptoms
Administering ATD prior surgery can help prevent thyroid storm

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

Padda & Nguyen, 2021

American Thyroid Association, n.d.b

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Special Nursing Consideration for Hyperthyroidism in Children

Assess pregnant mother and children for hyperthyroidism
Timely and appropriate referral of suspected cases
Monitor

Heart rate, rhythm, blood pressure
Fluid intake output (diarrhea frequent in hyperthyroidism)
Daily weight

Beware of adverse effects of ATD, surgical interventions:

Allergic reactions
Decreased white blood cells, lower resistance to infections
Liver failure (rare cases)
Thyroid storm (due to general anesthesia)

Mathew, Rawla, & Fortes, 2021

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

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Special Nursing Consideration in Children with Hyperthyroidism in Children (Continued)

Refer to dietician for appropriate diet for weight gain, calcium intake
Child/parent education

Importance of taking medications as prescribed, and timely follow-up
Seek immediate medical advice in presence of:

Fatigue or weakness, dull abdominal pain, loss of appetite, skin rash/itching/easy bruising, yellowing of skin/eyes, constant sore throat, fever, chills

Avoid soda and caffeinated drinks
Sunglasses to protect eye from dryness, wind

Mathew, Rawla, & Fortes, 2021

National Institute of Diabetes and Digestive and Kidney Diseases, 2021b

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Critical Thinking Question

What would a nurse expect to find in the assessment of a child with hyperthyroidism? (Select all that apply)

Lethargy
Weight loss
Higher than normal level of thyroid stimulating hormone
Tachycardia
Difficulty sleeping

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Diabetes Mellitus (DM) in Children

Blood sugar level is abnormally high due to inadequate production of insulin or body’s inability to use insulin.
Type 1 DM

Autoimmune destruction of pancreatic beta cells leads to production of little or no insulin.
Most common type of DM, and most common chronic disease in children.

Type 2 DM

Body unable to use insulin effectively due to resistance to insulin.
Mainly caused by diet, lifestyle.

Calabria, 2020

Queensland Pediatric Endocrinology, n.d.

Pediatric Society of New Zealand, 2019a

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DM in Children: Complications

DM in Children: Signs/Symptoms

Diabetic ketoacidosis (DKA)
Hyperosmolar Hyperglycemic State (HHS)
Vascular disease- High cholesterol, high blood pressure, heart attacks, strokes

Calabria, 2020

Queensland Pediatric Endocrinology, n.d.

Pediatric Society of New Zealand, 2019a

Excessive thirst
Frequent urination
Hunger
Unintentional weight loss
Fatigue

Retinopathy
Nephropathy
Nerve problems

Blurring of vision
Acute metabolic deterioration (signs of severe dehydration, Kussmaul’s respiration, vomiting, altered level of consciousness)

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DM in Children: Assessment & Diagnostics

Medical history and physical exam focused on signs/symptoms, risk factors of DM
Blood sugar tests: Fasting blood sugar (FBS), oral glucose tolerance test (OGTT), random blood sugar (RBS)
Other tests: Hemoglobin A1c (HbA1c), Glucose or ketones in urine
Asymptomatic children with risk factors should be screened for type 2 DM

Risk factors: Overweight/obesity, physical inactivity, DM in first degree relatives, mother’s with history of gestational DM, cardiovascular disease and its risk factors,ethnicity (South Asian, Afro-Caribbean, Hispanic)

Queensland Pediatric Endocrinology, n.d.

World Health Organization, 2020

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World Health Organization (2020)

Diagnostic Criterias for DM

Measurements	Diagnostic cut-off values
Fasting venous or capillary** plasma glucose	≥7.0 mmol/L (126 mg/dL)
2-hour post-load venous plasma glucose	≥11.1 mmol/L (200 mg/dL)
2-hour post-load capillary** plasma glucose	≥12.2 mmol/L (220 mg/dL)
Random plasma glucose ≥11.1 mmol/L (Used only in presence of symptoms)	≥11.1 mmol/L (200 mg/dL)
HbA1c***	6.5% (48 mmol/mol)

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DM in Children: Management

DM cannot be cured but blood sugar level can be controlled
Type 1 DM:

Insulin by injection or pump
Dietician counselling for planned diet and regular exercise
Regular blood sugar measurement necessary to adjust insulin dose

Type 2 DM:

Oral hypoglycemic agents (OHA) with diet modifications and physical activity.
Dietician counselling for diet modification, regular exercise.
Weight loss in overweight/obese child.
Insulin might be needed if the above interventions does not work.

Queensland Pediatric Endocrinology, n.d.

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What Would the Nurse Do?

Which of the following are appropriate for a nurse to undertake while caring for a child with type 1 diabetes mellitus? (Select all that apply).

Inform the child and parent that the condition can be cured with strict adherence to medication and diet regimen for a couple of months
Inform child and parents that diet modification and exercise alone cannot manage type 1 diabetes mellitus
Teach the child and parent vastus lateralis and deltoid muscle are safe sites for insulin injection
Inform child and parents that regular blood sugar measurement is necessary to adjust insulin dose

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Management of Hypoglycemia

Generally defined as plasma glucose ≤3.9 mmol/L (70 mg/dL)
Sign/symptoms:

Feeling hungry
Looking pale
Shaky/trembling
Feeling dizzy
Feeling sweaty
Irritability
Confused
Lack of concentration

Pediatric Society of New Zealand, 2019b

World Health Organization, 2020

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Management of Hypoglycemia

Life-threatening condition, needs immediate action:

Child who can swallow should be given 15-20 g of fast-acting glucose.

Reassess after 10-15 minutes, repeat above step if needed.

Unconscious child: 20–50 mL of 50% glucose, intravenous (IV) over 1–3 minutes.

May need to be followed by complex carbohydrate when able to eat.

Pediatric Society of New Zealand, 2019b

World Health Organization, 2020

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DM Complications: DKA

Life threatening condition, meets all criterias below:

Blood glucose level (BGL) > 11mmol/L
Venous pH < 7.3 and/or HCO3 < 15 mmol/L
Moderate/large ketonaemia/ketonuria

Signs/symptoms:

Polydipsia, polyuria
Enuresis in toilet trained child
Weight loss, increased appetite
Vomiting
Abdominal pain
Signs of general malaise

Initial management:

Rehydration with IV Sodium Chloride 0.9% bolus
Cardiac monitoring for arrhythmias and ECG/T wave changes

Queensland Emergency Care of Children working group, 2021

World Health Organization, 2020

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The aim of fluid and electrolyte replacement therapy in DKA is:

restoration of circulating volume
replacement of sodium and water deficit over 48 hours
management of the predictable fall in the serum potassium concentration after insulin therapy commences and the ketoacidosis starts to reverse
restoration of GFR with enhanced clearance of glucose and ketones from the blood
administration of insulin therapy to normalise the BGL and to suppress lipolysis and ketogenesis
avoidance of cerebral edema, which may be caused by rapid fluid shifts from the extracellular fluid to the intracellular fluid compartment

(Queensland Emergency Care of Children working group, 2021)

Laboratory values for ketone in urine identified as:

Small: <20 mg/dL
Moderate: 30 to 40 mg/dL
Large: >80 mg/dL

(University of California San Francisco, 2019)

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Management of DKA (Continued)

IV Insulin required in moderate to severe DKA

Only short-acting insulin to be administered IV
Ideal dose: 0.1 units/kg/hr
Insulin infusion set should be changed every 24 hours

Potential for insulin to denature

Serum potassium replacement might be necessary with IV rehydration and insulin therapy

Potassium infusion rate should not exceed 0.3 mmol/kg/hr without consultation
Serum potassium monitored continuously

Queensland Emergency Care of Children working group, 2021

World Health Organization, 2020

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Management of DM Complications: HHS

Extreme hyperglycemia without ketosis, meeting all criteria below:

BGL > 33.3 mmol/L
Venous pH > 7.3 and/or HCO3 > 15 mmol/L
Small ketonuria
Absent to mild ketonemia < 1.1 mmol/L
Effective serum osmolality > 320 mOsm/kg

Typically presents with altered level of consciousness
Immediate management: management of airway, breathing, circulation and disability (ABCD), and aggressive fluid resuscitation
Early Pediatric Intensive Care Unit management required

Queensland Emergency Care of Children working group, 2021

World Health Organization, 2020

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Special Nursing Considerations for Children with DM

Assess risks for DM
Prompt referral of suspected cases to specialist for timely management.
Ensure child/parent is counselled by dietician for appropriate diet plan.
Emphasize to child/parent the importance of strict adherence to medication regime, exercises/physical activities, and planned diet for prevention of complications.
Monitor for and appropriately manage complications like hypoglycemia, DKA, HHS.
Ensure child/parent’s questions and concerns are addressed.

World Health Organization, 2020

Queensland Pediatric Endocrinology, n.d.

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Special Nursing Considerations…(Continued)

Child/Parent education

How to prevent DM in at risk children
Insulin injection if prescribed

Correct dose, correct technique, identifying subcutaneous sites
Rotating injection sites to prevent lumps/fatty deposits

About OHAs prescribed
Identification and quick management of hypoglycemic episode or DKA
When to seek medical advice

Empower affected child to take charge of managing his/her diabetes
Adjust care to child’s cognitive and physical abilities

World Health Organization, 2020

Queensland Pediatric Endocrinology, n.d.

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What Would the Nurse Do?

Random blood sugar (RBS) test of a 14 year old diabetic teenager read 3.3 mmol/L. On, further assessment, the nurse found blood pressure 118/76 mmHg, heart rate 72 beats/min, temperature 37oC, respiratory rate 14 breaths/minute. Nurse noticed that the teenager was pleasantly talking to her mother. What should the nurse do next?

Monitor the teenager for signs of hypoglycemia
Immediately treat hypoglycemia by providing the teenager sugary juice to drink
Take RBS test again with another RBS working glucometer
Document RBS reading and inform the doctor.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

Consider cultural preferences for food and eating habits for appropriate education on diet.
Identify and clear the false beliefs regarding DM, insulin and other treatment regime.
Clarify child/parent that ‘injection human insulin’ is produced from bacteria and not from human body itself.
Beware some cultures might not accept animal product based medicine.

Pork insulins, pork-based synthetic insulins, and beef (non-halal) insulins are unacceptable to devoted Muslims.

Qureshi, 2002

Rebolledo & Arellano, 2016

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References:

American Thyroid Association. (n.d.a). Hypothyroidism in Children and Adolescents. https://www.thyroid.org/hypothyroidism-children-adolescents/

American Thyroid Association. (n.d.b). Hyperthyroidism in Children and Adolescents. https://www.thyroid.org/hyperthyroidism-children-adolescents/

Calabria, A. (2020a, July). Hypothyroidism in Infants and Children. MSD Manuals Professional Version. https://www.msdmanuals.com/professional/pediatrics/endocrine-disorders-in-children/hypothyroidism-in-infants-and-children

Calabria, A. (2020b, July). Hyperthyroidism in Infants and Children. MSD Manuals Professional Version. https://www.msdmanuals.com/professional/pediatrics/endocrine-disorders-in-children/hyperthyroidism-in-infants-and-children

Contact info: info@nursesinternational.org

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References:

Calabria, A. (2020c, July). Diabetes Mellitus in Children and Adolescents. MSD Manual Professional Version. https://www.msdmanuals.com/professional/pediatrics/endocrine-disorders-in-children/diabetes-mellitus-in-children-and-adolescents?query=Diabetes%20Mellitus%20(DM)%20in%20Children%20and%20Adolescents

Foley, M., Sather, R., & Hurd, R. (n.d.). Acquired Hypothyroidism in Children. University of Rochester Medical Center. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=160&contentid=4

John Hopkins Medicine. (n.d.). Hypothyroidism in Children. https://www.hopkinsmedicine.org/health/conditions-and-diseases/hypothyroidism-in-children

Lucile Packard Children’s Hospital Stanford. (n.d.). Congenital Hypothyroidism in Children. https://www.stanfordchildrens.org/en/topic/default?id=hypothyroidism-in-children-90-P01963

Contact info: info@nursesinternational.org

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References:

Mathew, P., Rawla, P., & Fortes, K. (2021, December 12). Hyperthyroidism (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568782/

MedlinePlus. (2015, September 1). Congenital hypothyroidism. National Library of Medicine, National Institute of Health. https://medlineplus.gov/genetics/condition/congenital-hypothyroidism/#inheritance

National Institute of Diabetes and Digestive and Kidney Diseases. (2021a, March). Hypothyroidism (Underactive Thyroid). https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism#complications

National Institute of Diabetes and Digestive and Kidney Diseases. (2021b, August). Hyperthyroidism (Overactive Thyroid). https://www.niddk.nih.gov/health-information/endocrine-diseases/hyperthyroidism

Contact info: info@nursesinternational.org

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References:

Padda, I.S., & Nguyen, M. (2021, November 25). Radioactive Iodine Therapy. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557741/

Pediatric Society of New Zealand. (2019a, April 10). Diabetes in Children- An Overview. https://www.kidshealth.org.nz/diabetes-children-overview

Pediatric Society of New Zealand. (2019b, April 9). Hypoglycemia in Children with Diabetes. https://www.kidshealth.org.nz/hypoglycaemia-children-diabetes

Queensland Emergency Care of Children working group. (2021). Queensland Pediatric Guideline: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS) - Emergency management in children. Children’s Health Queensland Hospital and Health Service. https://www.childrens.health.qld.gov.au/guideline-dka-emergency-management-in-children/

Queensland Pediatric Endocrinology. (n.d.). About Diabetes (diabetes mellitus). https://www.qldpaedendocrinology.com.au/about-diabetes.html

Contact info: info@nursesinternational.org

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References:

Qureshi, B. (2002). Diabetes in Ramadan. Journal of the Royal Society of Medicine, 95(10), 489–490. https://doi.org/10.1258/jrsm.95.10.489

Rebolledo, J. A., & Arellano, R. (2016). Cultural Differences and Considerations When Initiating Insulin. Diabetes spectrum : a publication of the American Diabetes Association, 29(3), 185–190. https://doi.org/10.2337/diaspect.29.3.185

Shanholtz, H.J. (2013). Congenital Hypothyroidism. Journal of Pediatric Nursing, 28(2): 200-202. https://www.pediatricnursing.org/article/S0882-5963(13)00017-1/fulltext#relatedArticles

World Health Organization. (‎2020)‎. HEARTS D: diagnosis and management of type 2 diabetes. World Health Organization. https://apps.who.int/iris/handle/10665/331710. License: CC BY-NC-SA 3.0 IGO

Contact info: info@nursesinternational.org

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