Inpatient Pediatric Endocrinology. Tala Dajani MD MPH Pediatric Endocrinology of Phoenix

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1 Inpatient Pediatric Endocrinology Tala Dajani MD MPH Pediatric Endocrinology of Phoenix

2 Objectives Identify calcium disorders in the hospital Distinguish between temporary versus permanent glucose problems during illness Describe thyroid function in the hospitalized patient Assess adrenal function inpatient

3 Case 1 1 month old admitted with irritability and recurrent muscle spasms Refugee from Nigeria Mom reports decreased po intake She reports trouble with breastfeeding Serum calcium: 7.5 mg/dl

4 Hypocalcemia Calcium is the most abundant mineral in the body Bone : 99% is stored in bone Serum < 1% Peripheral and CNS effects Paresthesias Tetany :contraction of hands, arms, feet, larynx, bronchioles Seizures Psychiatric changes

5 Differential Diagnosis

6 Differential Diagnosis Vitamin D deficiency Liver disease PTH deficiency DiGeorge syndrome, velocardiofacial (Shprintzen) syndrome or 22q11 deletion syndrome VATER/VACTERL CHARGE Magnesium deficiency Activating mutations calcium-sensing receptor

7 Differential Diagnosis Hyperphosphatemia Renal failure Excessive phosphate intake Increased endogenous phosphate Anoxia Chemotherapy Rhabdomylosis Alkalosis

8

9 Evaluation Total and ionized Calcium Magnesium Phosphorus CMP: ALP, Albumin, K+, glucose Intact PTH 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D Urine calcium, phos, magnesium

10 Case 1 results Magnesium: 1.9 mg/dl Phosphorus: 7.3 mg/dl CMP: Glucose 72 mg/dl, creat 0.21mg/dL, Alb 4.0, ALP 230 IU/L, K 4.5 Intact PTH: 80 ng/l 25-hydroxyvitamin D: 35 ng/ml; 1,25-dihydroxyvitamin D: 55 pg/ml Alkalosis eval: no hyperventilation, CO2: 25

11 Calcium PTH Interpretation Normal Normal Calcium regulation system functioning OK Low High PTH is responding correctly; may run other tests to check for other causes of hypocalcemia Low Normal or Low PTH not responding correctly; probably have hypoparathyroidism High High Parathyroid gland producing too much PTH; may do imaging studies to check for hyperparathyroidism High Low PTH is responding correctly; may run other tests to check for non-parathyroid-related causes of elevated calcium Normal High Mild hyperparathyroidism

12 Mom was providing cow s milk as formula Whole cow's milk has 7 times the phosphate load of breast milk 956 vs 140 mg/l in breast milk

13 Case 2

14 Case 2 12 year old boy inpatient treatment for asthma exacerbation Has has not been able to take po Methylprednisone 60 mg Q 6 hours CMP: BG 201 mg/dl Is this stress hyperglycemia or new onset diabetes mellitus?

15 Stress Hyperglycemia Transient hyperglycemia due to the stress of illness Resolves spontaneously mg/dl but can be > 500 mg/dl Seen with dehydration, emergency visit Steroid diabetes: prolonged form of stress hyperglycemia Predisposition to diabetes mellitus Decreased insulin secretion

16 Stress Hyperglycemia Therapy Hyperglycemia in acutely ill patients as normal response to stress. Evidence shows negative correlation of hyperglycemia with survival in both adult and pediatric ICUs Incidence of hyperglycemia is high (69.3%) in critically ill children and it is associated with high morbidity and mortality Abnormalities in glucose homeostasis in critically ill children.bhutia TD, Lodha R, Kabra SK. Pediatr Crit Care Med Jan; 14(1):e16-25 Heart And Lung Failure - Pediatric INsulin Titration Trial (HALF-PINT) Children's Hospital Boston

17 Case 3 9 year old girl is admitted for treatment of AGE Mom reports several months of progressively worsening nausea and fatigue TSH 4.2, Free T4 0.6 Does she require thyroid hormone replacement?

18 Non-Thyroidal Illness sick euthyroid syndrome or low T3 syndrome occurs in fasting healthy subjects and acute severe illnesses adaptive and beneficial Decrease in energy expenditure to limit catabolism immediate suppression of the deiodinase type-1 TSH secretion is suppressed by fasting

19

20 Case 2 Did not have persistent hyperglycemia, no insulin needed OGTT 2 weeks post hospitalization, SNL Diagnosis: Stress hyperglycemia

21 Adrenal Function in the hospitalized child

22

23 Random Cortisol in critically ill Serum free cortisol measurement is the most reliable method to assess adrenal function in critically ill, hypoproteinemic patients A random serum free cortisol is expected to be 1.8 μg/dl or more in most critically ill patients Random serum total cortisol 15 μg/dl or more in critically ill patients with normal protein levels. 9.5 μg/dl or more in hypoproteinemic critically ill patients

24 Hydrocortisone replacement

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