Brush up on key

concepts
Together with the nervous system, the
endocrine system regulates and integrates
the body’s metabolic activities. Disorders of
the endocrine system involve hyposecretion
or hypersecretion of hormones, which affect
the body’s metabolic processes and function.
At any time, you can review the major
points of this chapter by consulting the Cheat
sheet on page 702.
Endocrine junior
Here are key points about endocrine functioning
in childhood:
• The pituitary gland controls the release
of nine different hormones and is the master
gland for all age-groups.
• The adrenal cortex begins secreting glucocorticoids
and mineralocorticoids early in
embryonic life.
• The thyroid gland, many times larger in
children than in adults, is functional at age
2 weeks. It’s thought to play a role in immune
function.
Ch..ch..changes
The pituitary is stimulated at puberty to
produce androgen steroids responsible for
secondary sex characteristics.
Female secondary sexual development
during puberty involves increase in the size of
the ovaries, uterus, vagina, labia, and breasts.
The first visible sign of sexual maturity is the
appearance of breast buds. Body hair appears
in the pubic area and under the arms and
menarche begins. The ovaries, present at
birth, remain inactive until puberty.
Male secondary sexual development consists
of genital growth and the appearance of
pubic and body hair.
A place to integrate
The endocrine system meets the nervous
system at the hypothalamus. The hypothalamus,
the main integrative center for the
endocrine and autonomic nervous systems,
controls the function of endocrine organs by
neural and hormonal pathways.
Neural pathways connect the hypothalamus
to the posterior pituitary, or neurohypophysis.
Neural stimulation to the posterior
pituitary provokes the secretion of hormones
(chemical transmitters released from specialized
cells into the bloodstream). Hormones
are then carried to specialized organ-receptor
cells that respond to them.
Negative feedback
In addition to hormonal and neural controls,
a negative feedback system regulates
the endocrine system. The mechanism of
feedback may be either simple or complex:
• Simple feedback occurs when the level
of one substance regulates secretion of a hormone.
For example, low serum calcium levels
stimulate parathyroid hormone secretion;
high serum calcium levels inhibit it.
• Complex feedback occurs through
an axis established between the hypothalamus,
pituitary gland, and target organ.
For example, secretion of the hypothalamic
corticotropin-releasing hormone stimulates
release of pituitary corticotropin which, in
turn, stimulates cortisol secretion by the
adrenal gland (the target organ). A rise in
serum cortisol levels inhibits corticotropin
secretion by decreasing corticotropinreleasing
hormone.

Endocrine refresher
HYPOTHYROIDISM
Key signs and symptoms
Congenital hypothyroidism
• Poor feeding
• Low temperature
• Hoarse crying
• Prolonged jaundice
Acquired hypothyroidism
• Lethargy, decreased energy
• Cold intolerance
• Heat intolerance
• Weight loss
Untreated hypothyroidism in older children
• Bone and muscle dystrophy
• Cognitive impairment
• Stunted growth (cretinism)
Key test results
• Radioimmunoassay confirms hypothyroidism
with low triiodothyronine and thyroxine levels.
Key treatments
• Oral thyroid hormone: levothyroxine (Synthroid)
Key interventions
• During early management of infantile hypothyroidism,
monitor blood pressure and pulse rate
and report hypertension and tachycardia immediately
(normal infant heart rate is approximately
120 beats/minute).
• Check rectal temperature every 2 to 4 hours.
Keep the infant warm and his skin moist.
• If the infant’s tongue is unusually large, position
him on his side and observe him frequently.
TYPE 1 DIABETES MELLITUS
Key signs and symptoms
• Polydipsia
• Polyphagia
• Polyuria
• Weight loss and hunger
Key test results
• Two fasting plasma glucose levels (no caloric
intake for at least 8 hours) are greater than or
equal to 126 mg/dl.
• Glycosylated hemoglobin level is greater than
7%.
• Plasma glucose value in the 2-hour sample of
the oral glucose tolerance test is greater than or
equal to 200 mg/dl. This test should be performed
after a loading dose of 75 g of anhydrous glucose.
• A random plasma glucose value (obtained
without regard to the time of the child’s last
food intake) greater than or equal to 200 mg/dl
accompanied by symptoms of diabetes indicates
diabetes mellitus.
Key treatments
• Exercise
• Insulin replacement
• Strict diet planned to meet nutritional needs,
control blood glucose levels, and reach and
maintain appropriate body weight
Key interventions
• Monitor vital signs and intake and output.
• Use age-appropriate teaching materials when
teaching about diabetes and the therapeutic
regimen.

Keep abreast of
diagnostic tests
Here are some important tests used to
diagnose endocrine disorders, along with
common nursing interventions associated
with each test.
Function studies
An endocrine function study focuses on
measuring the level or effect of a hormone
such as the effect of insulin on blood glucose
levels.
Sophisticated techniques of hormone
measurement have improved diagnosis of
endo crine disorders. For example, the human
growth hormone stimulation test measures
human growth hormone levels after I.V.
administration of arginine, an amino acid
that, under normal circumstances, stimulates
human growth hormone. This test is used to
diagnose growth hormone deficiency.
Nursing actions
• Explain the test to the child and his parents.
• Check with the laboratory and consult
facility protocol to determine specific actions
before the test (nothing-by-mouth for blood
glucose test).
Minute measurements
A radioimmunoassay is used to measure
minute quantities of hormones.
Nursing actions
• Explain the test to the child and his parents.

Polish up on client
care
Two major pediatric endocrine disorders are
hypothyroidism and type 1 diabetes mellitus.
Hypothyroidism
Hypothyroidism occurs when the body
doesn’t produce enough thyroid gland
hormones, the hormones necessary for
normal growth and development. (See
Thyroid gland hormones.)
Two types of hypothyroidism exist. Congenital
hypothyroidism is present at birth.
Acquired hypothyroidism is commonly due
to thyroiditis, an inflammation of the thyroid
gland that results in injury or damage to
thyroid tissue. Hypothyroidism is two times
more common in girls than in boys.
Early diagnosis and treatment offer the
best hope. Infants treated before age 3
months usually grow and develop normally.
Children who remain untreated beyond age
3 months and children with acquired hypothyroidism
who remain untreated beyond age
2 suffer irreversible cognitive impairment.
Skeletal abnormalities may also occur; however,
these may be reversible with treatment.
CAUSES
• Antithyroid drugs taken during pregnancy
(in infants)
• Chromosomal abnormalities
• Chronic autoimmune thyroiditis (in
children older than age 2)
• Defective embryonic development that
causes congenital absence or underdevelopment
of the thyroid gland (most common
cause in infants)
• Inherited enzymatic defect in the synthesis
of thyroxine (T4) caused by an autosomal
recessive gene (in infants)
• Irradiation of the thyroid gland
CONTRIBUTING FACTORS
• Prolonged gestation
• High birth weight
ASSESSMENT FINDINGS
General findings
• Delayed dentition
• Enlarged tongue
• Hypotonia
• Legs shorter in relation to trunk size
• Cognitive impairment (develops as the disorder
progresses)
• Short stature with the persistence of infant
proportions
• Short, thick neck; goiter
• Brittle nails
Congenital hypothyroidism
• Delayed stools at birth
• Prolonged jaundice
• Poor feeding
• Low temperature
• Decreased activity level
• Hoarse crying
• Galactorrhea
• Large fontanels
• Umbilical hernia
Acquired hypothyroidism
• Dry, scaly skin
• Lethargy, decreased energy
• Sleep disturbance
• Cold intolerance
• Constipation
• Heat intolerance
• Weight loss
• Sexual pseudoprecocity
Untreated hypothyroidism in older children
• Bone and muscle dystrophy
• Cognitive impairment
• Stunted growth (cretinism)
DIAGNOSTIC TEST RESULTS
• Electrocardiogram shows bradycardia and
flat or inverted T waves in untreated infants.
• Hip, knee, and thigh X-rays reveal
absence of the femoral or tibial epiphyseal
line and delayed skeletal development
that’s markedly inappropriate for the child’s
chronological age.
• In myxedema coma, laboratory tests
may also show low serum sodium levels,
decreased pH, and increased partial pressure
of arterial carbon dioxide, indicating
respiratory acidosis.
• Increased gonadotropin levels accompany
sexual precocity in older children and may
coexist with hypothyroidism.
• Serum cholesterol, alkaline phosphatase,
and triglyceride levels are elevated.
• Normocytic normochromic anemia is
present.
• Radioimmunoassay confirms hypothyroidism
with low triiodothyronine (T3) and T4
levels.
• Thyroid scan and 131I uptake tests
show decreased uptake levels and confirm
the absence of thyroid tissue in athyroid
children.
• Thyroid-stimulating hormone (TSH) level
is decreased when hypothyroidism results
from hypothalamic or pituitary insufficiency.
• TSH level is increased when hypothyroidism
results from thyroid insufficiency.
NURSING DIAGNOSES
• Delayed growth and development
• Interrupted family processes
• Deficient knowledge (treatment regimen)
• Imbalanced nutrition: Less than body
requirements
• Activity intolerance
• Risk for imbalanced body temperature
TREATMENT
• Routine monitoring of T4 and TSH levels
• Periodic evaluation of growth to ensure
thyroid replacement is adequate
• Surgery to remove massive goiter (rare)
Drug therapy
• Oral thyroid hormone: levothyroxine (Synthroid)
INTERVENTIONS AND RATIONALES
• During early management of infantile
hypothyroidism, monitor blood pressure and
pulse rate; report hypertension and tachycardia
immediately (normal infant heart rate
is approximately 120 beats/minute). These
signs of hyperthyroidism indicate that the dose
of thyroid replacement medication is too high.
• Check rectal temperature every 2 to
4 hours. Keep the infant warm and his skin
moist to promote normothermia and reduce
metabolic demands.
• If the infant’s tongue is unusually large,
position him on his side and observe him frequently
to prevent airway obstruction.
• Provide parents with support, referrals,
and counseling as necessary to help parents
cope with the possibility of caring for a physically
and cognitively impaired child.
• Adolescent girls require future-oriented
counseling that stresses the importance of
adequate thyroid replacement during pregnancy.
Ideally, women should have excellent
control before conception.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects
• Recognizing signs of overdose of supplemental
thyroid hormone (rapid pulse rate,
irritability, insomnia, fever, sweating, weight
loss)
• Understanding that the child requires lifelong
treatment with thyroid supplements
• Complying with the treatment regimen to
prevent further mental impairment
• Adopting a positive but realistic attitude
and focusing on the child’s strengths rather
than his weaknesses
• Providing stimulating activities to help the
child reach maximum potential (referring
parents to appropriate community resources
for support)
• Preventing infantile hypothyroidism
(emphasize the importance of adequate nutrition
during pregnancy, including iodine-rich
foods and the use of iodized salt or, in cases
of sodium restriction, iodine supplements)
Type 1 diabetes mellitus
Type 1 diabetes mellitus (formerly referred
to as juvenile diabetes or insulin-dependent
diabetes) is a chronic metabolic disease characterized
by absolute insulin insufficiency.
Children with this type of diabetes must inject
insulin to process carbohydrates, fat, and protein.
Type 1 diabetes is most commonly diagnosed
during childhood or adolescence but
can occur at any time from infancy to about
age 30. (See Understanding type 1 diabetes,
page 706.)
CAUSES
• Genetic predisposition
• Viral infection
• Autoimmune response
• Congenital absence of pancreas or islet
cells
• Pancreatic damage secondary to another
disorder, such as cystic fibrosis or pancreatitis
• Chromosomal disorders such as Down
syndrome
ASSESSMENT FINDINGS
• Polydipsia
• Polyphagia
• Polyuria
• Weight loss and hunger
Hyperglycemia
• Abdominal cramping
• Dry, flushed skin
• Fatigue
• Fruity breath odor
• Headache
• Mental status changes
• Nausea
• Thin appearance and possible malnourishment
• Vomiting
• Weakness
Hypoglycemia in conjunction with diabetes
• Behavior changes (belligerence, confusion,
slurred speech)
• Diaphoresis
• Palpitations
• Tachycardia
• Tremors
DIAGNOSTIC TEST RESULTS
• Two fasting plasma glucose levels (no
caloric intake for at least 8 hours) are greater
than or equal to 126 mg/dl.
• Glycosylated hemoglobin level is greater
than 7%.
• Plasma glucose value in the 2-hour sample
of the oral glucose tolerance test is greater
than or equal to 200 mg/dl. This test should
be performed after a loading dose of 75 g of
anhydrous glucose.
• A random plasma glucose value (obtained
without regard to the time of the child’s last
food intake) greater than or equal to 200 mg/dl
that’s accompanied by symptoms of diabetes
indicates diabetes mellitus.
NURSING DIAGNOSES
• Disturbed body image
• Risk for imbalanced nutrition: Less than
body requirements
• Risk for imbalanced fluid volume
• Deficient knowledge (treatment regimen)
TREATMENT
• Exercise
• Strict diet planned to meet nutritional
needs, control blood glucose levels, and reach
and maintain appropriate body weight
Drug therapy
• Insulin replacement
INTERVENTIONS AND RATIONALES
• Monitor vital signs and fluid intake and
output to detect signs of hyperglycemia or hypoglycemia.
• Monitor blood glucose levels and
electro lytes to detect early signs of electrolyte
imbalance.
• Observe neurologic status to detect signs of
hyperglycemia or hypoglycemia.
• Evaluate the child’s or adolescent’s understanding
of type 1 diabetes and his attitude
about the need to manage it to help plan
teaching.
• Use age-appropriate teaching materials
when teaching about diabetes and the
therapeutic regimen to increase the child or
adolescent’s knowledge of his condition and
instill confidence in his ability to manage it.
• Provide an opportunity for the child or
adolescent to interact with peers who have
experienced diabetes to decrease his feelings of
isolation and being different from others.
Hyperglycemia
• Administer regular insulin for fast action
to promote euglycemic state and prevent
complications.
• Administer I.V. fluids without dextrose to
flush out acetone and maintain hydration.
• Monitor electrolyte and arterial blood gas
levels to detect imbalances or acidosis.
• Monitor blood glucose level to detect early
changes and prevent complications such as diabetic
ketoacidosis.
Hypoglycemia
• Give a fast-acting carbohydrate, such as
honey, orange juice, or sugar cubes, followed
later by a protein source to increase glucose
levels thereby preventing complications of hypoglycemia.
• If the child is stuporous or unconscious,
administer glucagon (subcutaneously, I.V., or
I.M.) or dextrose 50% I.V. to prevent complications
of hypogly cemia.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects
• Dietary adjustments
• Complying with the prescribed treatment
program (see Teaching about insulin
administration)
• Monitoring blood glucose levels
• Understanding the importance of good
hygiene
• Preventing, recognizing, and treating
hypoglycemia and hyperglycemia
• Understanding the effect of blood glucose
control on long-term health
• Managing diabetes during a minor illness,
such as a cold, the flu, or an upset stomach
• Providing the child or adolescent with written
materials that cover the teaching topics
• Providing the child and his family with
information about the Juvenile Diabetes
Foundation