pediatric endocrinology sarah lawrence division of endocrinology cheo
TRANSCRIPT
Pediatric Endocrinology
Sarah Lawrence
Division of Endocrinology
CHEO
Type 1 Diabetes
Epidemiology of Type 1 Prevalence 0.4% of individuals < 18 years Increased risk to family members
Sibling 5%
Father with diabetes 6-8%
Mother with diabetes 2-3%
Identical twin 30-50%
Type 1 Diabetes%
Bet
a C
ells
Time
Genetic predisposition
Environmental insult
Antibody positive
Diabetes
Diagnostic Criteria FBG > 7.0 mmol/L OR
Casual BG > 11.1 with symptoms OR
2 hour BG in OGTT of > 11.1
INITIAL MANAGEMENT
New Onset DM: Baseline labs Glucose, urea, creat, lytes, gas Urine for glucose and ketones TSH, thyroid antibodies
New Onset DM: Diet 1000 kcal + 100 kcal/year of age
i.e. 8 yo child = 1000 + 800 = 1800 kcal
3 meals and 3 snacks
Currently use exchange system, but changing to carbohydrate counting Starch 15 g Fruit/Sugar 10 g Dairy 6 g
BG Targets
Age (years) Premeal target (mmol/L)
HbA1c Target (%)
< 5 6-12 < 9.0%
6-12 4-10 < 8.0%
>12 4-8 < 7.0%
HbA1c & BG levels
New Onset - Insulin Dose By weight: 0.5 – 0.75
unit/kg/day 2/3 am, 1/3 pm 2/3 N, 1/3 H i.e. 8 yo, 25 kg
By age Am N = 1 unit/year of age AM H is 50% of this PM dose is 50% of the
am dose
8 yo
am pm
8N 4H 4N 2H
25 x( 0.5) = 15
Am 10 U Pm 5 U
3.5 N 1.5 H7 N 3 H
am noon pm hsam
Twice Daily Insulin:NPH + R/analogue
am noon pm hsam
Three Times Daily Insulin:NPH + R/analogue
Basal-Bolus Insulin Therapy: Insulin Glargine at HS and Mealtime Lispro or Aspart
B DL HS
Insulin Glargine or Levemir
Insulin Lispro or Aspart
Time of administration
B, breakfast; L, lunch; D, dinner; HS, bedtime.
Adapted from:1. Leahy JL. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker, Inc.; 2002.2. Bolli GB, et al. Diabetologia. 1999;42:1151–1167.
Type 1 DM
0
1
2
3
4
5
6
7
8
24 3 8 12 18 20 24Time
Insu
lin
Correction BolusMeal Bolus
Basal
Insulin Injection Sites
Picture of lipohypertrophy
Insulin adjustment: basic principles New onset, making daily changes until stabilized Established diabetesHighs:
High BG same time of day x 3 consecutive days Increase 10% at a time
Lows: Unexplained lows 2x/week same time of day 10-20% at a time
Insulin adjustment: basic principlesTime of Day Insulin to adjust
Morning pm N
Noon am R
Supper am N
Bed pm R
am noon hspm am
R R
NN
Hypoglycemia Causes:
Too much exercise/activity for which you did not plan
Not enough food and/or delay in getting the meal/snack
Too much insulin
Treatment:<20 kg 10 g CHO
>20 kg 15 g CHO
Hypoglycemia Severe hypoglycemia
Glucagon <5 years 0.5 mg > 5 years 1 mg
Minidose glucagon protocol Persistently low but alert and unable to
manage orally (e.g. during illness or inadvertent insulin error)
DKA: How common is it? At diagnosis of diabetes
15-67% present with DKA
Established diabetes 1-10% of patients/year
Cerebral edema 0.4-1% of episodes of DKA 25% mortality, up to 35% with severe
neurologic deficits
Cerebral Edema in DKA Who is at risk?
Increased risk in new onset DM, more dehydrated and acidotic patients
?treatment factors – rapid infusion of hypo-osmolar fluids, use of bicarbonate
Treatment – early intervention is key Raise HOB, + intubate, reduce fluids Mannitol, hypertonic saline
BG Ketones Insulin
<5 +/- Reduce N and R by 20%
5-14 +/- Give usual dose
>14 Neg to small (< 0.6)
Give 10% of TDD
>14 Moderate (++) (0.7-1.5)
Give 15% of TDD
>14 Large (3+/4+) (>1.5)
Give 20% of TDD
Insulin Dose Adjustment Guidelines for Intercurrent Illness
TDD = Total Daily Dose
Type 2 Diabetes in Children and Youth
Example: 95th Percentile Tracking Age BMI
2 yrs 19.3 4 yrs 17.8 9 yrs 21.013 yrs 25.1
For Children, BMI Changes with Age
Boys: 2 to 20 years
BMI BMI
BMI BMI
Genetic and Environmental Risk factors for T2DM Ethnicity Female gender Family history T2DM Intrauterine factors
Maternal history of gestational diabetes Large for gestational age (>4 kg) Small for gestational age (<2.5 kg)
Obesity Sedentary behaviour
Development of Type 2 DiabetesNormal
Insulin resistance
Impaired Glucose Tolerance
Type 2 Diabetes
Acanthosis Nigricans
Metabolic Syndrome in Youth by BMI
0.1
6.1
28.7
50
0
5
10
15
20
25
30
35
40
45
50
<8585-95>95>97
% w
ith
Met
abo
lic
Syn
dro
me
BMI Percentile
Treatment of T2DM in Youth Diabetes education for the family Setting glycemic targets
HbA1c < 7.0% Lifestyle modification
<10% achieve glycemic targets Pharmacotherapy
Metformin has been shown to have short term efficacy and safety in adolescents
Insulin rescue is required in those with severe metabolic decompensation at diagnosis
e.g. DKA, A1C ≥9.0%, symptoms of severe hyperglycemia, ketonuria
Presentation of T1DM vs T2DM Type 1 Type 2
Up to ¼ overweight
Short Course
25-40% DKA
FHx T1DM in 5-10%
Predominantly white
85% overweight
Indolent course
33% ketonuria5-25% DKAFHx T2DM 74-100%
Minority youth
Thyroid Disorders
Approach to Goitre
+ve
Chronic lymphocytic
thyroiditis
-ve
Goitrogen,
Dyshormonogenesis
Thyroid Antibodies
Elevated
Hypothyroid
TSH
Goitre
Suppressed
Hyperthyroid
Normal
Euthyroid
Hypothyroidism
Hypothyroidism - TreatmentMedication: Thyroxine 75-100 mcg/m2/day
Monitor every 6 months until growth complete, then annually:
SSx hypo/hyperthyroidismGrowthSexual maturationTSH (aim for 0.25-5 mU/L)+ FT4
Recheck TSH 4-6 weeks after dose adjustment
Approach to Goitre
+ve
Chronic lymphocytic
thyroiditis
-ve
Goitrogen,
Dyshormonogenesis
Thyroid Antibodies
Elevated
Hypothyroid
+ve/-ve: Graves
Hashitoxicosis
Subacute thyroiditis
Thyroid Antibodies
Suppressed
Hyperthyroid
TSH
Goitre
Normal
Euthyroid
Graves Disease
Hashitoxicosis / Subacute thyroiditis
TSH
Time
FT4
Hyperthyroid phase Hypothyroid phase
Hyperthyroidism - ManagementMedical Management
Antithyroid medicationsMethimazole (MMI, TapazoleTM) Initial dose: 0.4-0.6 mg/kg/day q8-12hMaintenance:0.2-0.3 mg/kg/day q12-24h
Propylthiouracil (PTU)Initial Dose: 4-6 mg/kg/day q6-8hMaintenance 2-3 mg/kg/day q 12h (-24h)
PropranololIodide
Radioactive IodineSurgery
Hyperthyroidism - ManagementSide Effects of Antithyroid medications:
Mild - pruritis, rash, abdominal pain, neutropenia,
Serious - agranulocytosis, arthropathy, lupus-like syndrome, hepatitis
Hyperthyroidism - ManagementMedical Management - Monitoring
Initially monitor q 4-6 weeks until T4 stabilized on maintenance doses of MMI/PTU, then q 3-4 months.
Clinical status
T4, TSH
Generally continue treatment for 2 years then try off tx and monitor closely for relapse
Approach to Goitre
+ve
Chronic lymphocytic
thyroiditis
-ve
Goitrogen,
Dyshormonogenesis
Thyroid Antibodies
Elevated
Hypothyroid
+ve
Chronic lymphocytic
thyroiditis
-ve
Colloid goitre
Thyroid Antibodies
Normal
Euthyroid
+ve/-ve
Grave's disease,
Subacute thyroiditis
Thyroid Antibodies
Suppressed
Hyperthyroid
TSH
Goitre
Subclinical Hypothyroidism
Normal SubclinicalOvert
Hypothyroidism Hypothyroidism
TSH N
FT4 N N
Summary Thyroid disorders are common in children and
adolescents
Most commonly present with goitre secondary to autoimmune thyroiditis or a simple colloid goitre
TSH and thyroid antibodies is usually all that is required to establish the diagnosis
Ultrasound should be limited to those with a palpable nodule
Summary The normal range of TSH may be higher
in the pediatric population leading to over-investigation /diagnosis and treatment of thyroid disorders
Mild elevations of TSH should be verified on repeat testing TSH <10mU/L often normal on repeat
Summary Natural history studies suggest a high
rate of spontaneous resolution with autoimmune thyroid disease and thus, repeat testing should be done before committing to lifelong thyroid hormone replacement
Precocious Puberty
Presence of secondary sexual development by age:
8 in a girl
9 in a boy
Approach to Precocious Puberty
Growth Velocity
Bone Age
Premature Thelarche
Estrogen
Premature Adrenarche
Androgens
Normal variant
Normal
Central
Androgens Estrogen
Peripheral
Pathological
Increased
Precocious Puberty
Approach to Precocious Puberty: Females
Premature
Thelarche
Estrogen
Premature
Adrenarche
Androgens
Normal Variant
Normal
Estrogen
+/- androgens
Central
Ovary
Adrenal
Other
Estrogen
Ovary
Adrenal
Other
Androgens
Peripheral
Pathological
Increased
Bone age, GV
Approach to Precocious Puberty: Males
Premature
Adrenarche
Androgens
Normal Variant
Normal
Testes > 4ml
Central
Testes
Adrenal
Other
Androgens
Testes
Adrenal
Other
Estrogen
Peripheral
Pathological
Increased
Bone age, GV
Delayed Puberty
Absence of secondary sexual development by age:
13 in a girl
14 in a boy
Constitutional Delay
of Growth and Puberty
Hypothalamic or
Pituitary Cause
Central
Low
Gonadal Failure
Peripheral
High
LH, FSH
Delayed Puberty
Approach to Delayed Puberty
Delayed Puberty: Investigations Growth records
Bone age
LH, FSH
Sex hormone levels - not needed
Other hormones as clinically indicated (T4, TSH, GH, Prolactin, Cortisol)
Delayed Puberty: Treatment Constitutional Delay of Growth and Puberty
Boys: Treat if psychologically distressed Depot testosterone 75-100 mg IM monthly x 3
Girls: Usually don’t treat (even low dose estrogens cause
accelerated skeletal maturation)
Delayed Puberty: TreatmentHyper / Hypogonadotropic Hypogonadism
Boys: Testosterone intramuscular injection, transdermal patch/gel or
orally, gradually increasing to adult doses
Girls: Start with low dose estrogen, increasing over 1-2 years, then begin
cycling with estrogen and progesterone
Short Stature
Approach to Short Stature
Growth velocity
Target Height
Familial Short Stature Constitutional Delay
Normal Variant
IUGR
Dysmorphic syndromes
Chromosomal disorders
Prenatal
Medications
Chronic disease
Endocrine
Postnatal
Proportionate Disproportionate
Pathologic
Short Stature
Idiopathic Short Stature
Chronic Disease
Endocrinopathy