Easy Pediatrics

Therapy for patients with diabetic ketoacidosis DKA involves careful replacement of fluid deficits, correction of acidosis and hyperglycemia via insulin administration, correction of electrolyte imbalances and monitoring for complications of treatment.

1. Dehydration

A patient with severe DKA is assumed to be approximately 10% dehydrated. An initial IV fluid bolus of a glucose-free isotonic solution ( normal saline, lactated Ringer’s solution) at 10-20 ml/kg should be given to restore intravascular volume and renal perfusion. The remaining fluid deficit after the initial bolus should be added to maintenance fluid requirements, and the total should be replaced slowly over 36 to 48 hrs. To avoid rapid shifts in serum osmolality, 0.9% sodium chloride can be used as the replacement fluid for the initial 4 to 6 hrs followed by 0.45% sodium chloride.

2. Hyperglycemia

Fast-acting soluble insulin should be administered as a continuous IV infusion (0.1U/kg/hr). Serum glucose concentration should decrease at a rate no faster than 100 mg/dl/hr. When serum glucose concentration decreases to less than 250-300 mg/dl, glucose should be added to IV fluids.

3. Acidosis

Insulin therapy lowers glucagon and diminishes its activity on liver, decreases the production of free fatty acids and protein catabolism, and enhances glucose usage in target tissues. theses processes correct acidosis. Bicarbonate therapy should be avoided unless there is severe acidosis ( pH < 7.0).

4. Electrolyte Imbalances

Regardless of the serum potassium concentration at presentation, total body potassium depletion is likely. When adequate urin output is shown potassium should be added to the IV fluids. Potassium replacement should be given as 50% KCl and 50% KPO4 at a concentration of 20-40 mEq/L.

5. Monitoring

A flow sheet should be used to record and monitor fluid balance and laboratory measurements. Serum glucose measurements should be repeated every hour during therapy and electrolyte concentrations should be repeated every 2 to 3 hours. Calcium, phosphate and magnesium concentrations should be measured initially  and then every 4 to 6 hours during therapy.  Continue reading »

• Disturbances of growth are the most common presenting complaints in the pediatric endocrine clinic.
  • Fetal growth is dependent on maternal factors (placental sufficiency, maternal nutrition, etc.), insulin-like growth factor-2 (IGF-2) and insulin.
  • Growth in late infancy and childhood is dependent on growth hormone/IGF-1 axis and thyroid hormone. Growth is more rapid during infancy—up to 20 cm per year. It is common to see shifts in the growth curve in the first 18 months when children are adjusting to their genetic potential growth isopleth. During childhood, growth rate is fairly constant at approximately 2 inches (approximately 5 cm) per year.
  • Pubertal growth is dependent on sex hormones as well as growth hormone/IGF-1 axis and the thyroid gland. There is a mild deceleration in growth velocity before initiation of pubertal growth spurt.
• Abnormal growth and stature: criteria
  • Child’s growth curve is crossing percentiles.
  • Child’s growth rate is <2 inches or 5 cm per year.
  • Height is >2 standard deviations (SDs) (4 inches/10 cm) below from midparental height.
• If poor weight gain and lack of nutrition is the problem without affecting height velocity, it is unlikely to be an endocrine cause and patient may warrant a gastrointestinal evaluation instead.