Endocrinology+Round+1

** Endocrinology Round 1: ** ** The Endocrine System: **

Endocrine system is composed of glands, which secrete chemicals called hormones. The hormones affect multiple target tissues and organs in the body. Hormones regulate growth, fluid and electrolytes, energy, sexual maturation, reproduction and stress response .

Disorders  are caused by insufficient hormones (Hypofunction), most common Or excessive hormones (Hyperfunction) Endocrine system... seesaw which can go up and down creating a problem with homeostasis in susceptible children.

Primary  (the affected gland doesn’t work), Secondary <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> (the pituitary inadequately stimulates the target gland) <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Tertiary <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> (the hypothalamus is the cause of the problem).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The endocrine system is the most <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> immature body system at birth <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The endocrine system is closely <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">linked to the central nervous system (CNS).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Glands in endocrine system are the <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> hypothalmus, adrenal, pituitary, pineal, pancreatic islets, parathyroid, thyroid, thymus, ovaries and testes <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">. Most have clear roles except the pineal and the thymus gland.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Curiously, the pineal gland is about the size of a raisin and usually calcified by age 12. It is thought that it may have some something to do with melatonin production while the thymus is generally thought to be part of the immune system.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*The production and secretion of hormones is controlled by a negative feedback system.*


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">A great review of the endocrine system! **

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 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Newborn Screening: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">This is a fact sheet about newborn screening located at the SCDHEC. The link is below. **

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">**Newborn Screening F.A.Q. Sheet**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**How long has DHEC done this testing?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Testing for <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">phenylketonuria (PKU) <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> began in 1965. A 1976 law made testing mandatory unless parents had religious objections. The other tests were recommended by the Newborn Screening Advisory Committee and approved by the DHEC board.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**What diseases are on the test panel?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">The SC newborn screening panel includes all <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">28 core metabolic conditions <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> that are recommended by the March of Dimes and the American College of Medical Genetics. In addition it also includes screening for 24 secondary metabolic conditions that can cause severe problems if not found very early in life. The most common conditions are described below.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Phenylketonuria// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> is an error in amino acid metabolism resulting in profound mental retardation. The consequences can be avoided by very early detection and a diet low in the amino acid phenylalanine. About three babies with PKU are detected each year. Testing can also identify babies with other amino acid metabolism disorders as well as babies with certain organic acid metabolism disorders.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Congenital Hypothyroidism// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> results from the lack of thyroid hormone leading to mental retardation and slow growth. If detected early, thyroid hormone can be given and the consequences reduced or eliminated. About 20 babies are found each year with primary congenital hypothyroidism.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Persons with <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Hemoglobinopathies (like Sickle Cell Disease)// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> may have impaired oxygen transfer ability and many painful and life-threatening conditions, some of which can be prevented through early diagnosis and monitoring. About 100 babies a year are identified with hemoglobinopathy disorders including sickle cell disease while another 2,400 are identified as carriers.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Galactosemia// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">is caused by an inability to metabolize galactose, a component of lactose found in milk and other foods. Serious gastrointestinal disturbances, failure to gain weight and jaundice may occur. Children with untreated galactosemia develop mental retardation, cataracts and speech delay. Some babies die in the early neonatal period from bacterial sepsis. If detected early, diets low in galactose can minimize the effects of the condition. About one baby a year is born with this condition. Other, less severe forms of galactosemia can also be found through this testing. In SC, around 15 babies are found with less severe forms of galactosemia each year.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Congenital adrenal hyperplasia// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">is an enzyme defect that affects the functioning of the adrenal gland with the overproduction of testosterone. Children with CAH may begin puberty at 3-5 years of age. In some cases, the child may experience dehydration, shock and death. Administration of adrenal hormones can prevent some serious consequences. About three babies a year are identified with this condition.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Medium chain acyl-CoA dehydrogenase// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> deficiency causes an error in fatty acid metabolism resulting in a child's blood sugar becoming dangerously low. About 20 percent of children with MCADD die before diagnosis if screening is not in place and those who survive may have serious residual effects. If detected early, the condition can be treated by making sure the child gets enough carbohydrate, especially during illness or other stressful times. About four babies a year are found with this condition. Testing can also identify babies with other fatty acid metabolism disorders.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Biotinidase deficiency// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> causes a baby to have difficulty using biotin, a vitamin that is found in foods, including breast milk and infant formula. Without biotin, the baby will not grow and develop properly. He or she may have seizures, hearing loss and skin problems. About one baby a year is found with this disorder.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">//Cystic fibrosis// <span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;"> is a genetic disorder that is detected in 10 to 15 babies born in SC each year. When a baby has CF, some fluids in the body that should be thin and slippery are thick and sticky. These fluids can plug up some of the “tubes” or “channels” in the body. This affects the lungs and digestive system the most. Babies with CF often cough or wheeze and can get lung infections that need treatment with strong drugs. They also may not digest their food well, often in spite of a huge appetite. Poor digestion can cause diarrhea and poor growth. Babies found through screening often have not yet started to show much of these problems or to “act sick”.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**Do parents sign a consent form?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">There is no DHEC consent form for newborn screening. The DHEC Newborn Screening Manual; Law, Regulations, and Official Departmental Instructions states, "The provision of the screening test is covered under the informed consent signed by the parents at the hospital." Parents may refuse the tests only on religious objections.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**Do parents get any information in advance?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">The regulation requires hospital staff to provide information about the testing. The hospital may give the parents a pamphlet with information about the testing.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**How long does it take to do the testing?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">On average, testing is completed three working days after the specimen arrives in DHEC’s laboratory. If the results indicate a high likelihood that the infant has a newborn screening disorder, the physician of record is notified by phone by staff in the Division of Women and Children’s Services. If the results are less definite but still abnormal, the physician will be notified by mail. The laboratory needs to keep the specimens, which are blood spots, long enough to complete testing and allow for requests for routine additional tests or repeats.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**What happens to the information?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">Results are sent to the hospital or mid-wife and to the physician of record. Abnormal results are also immediately sent to DHEC’s Division of Women and Children’s Services for follow-up. The results from children with sickle-cell trait (carriers of sickle cell) are sent by the Laboratory to regional sickle-cell centers for counseling and follow-up.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**What happens to the blood specimens after laboratory testing is completed?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">The laboratory will destroy the residual blood specimens once they are no longer needed for testing. They are not used in research or for any purpose other than newborn screening.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">**Does DHEC do any DNA-based newborn screening or store purified DNA?**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18.200000762939453px;">No. DHEC does no DNA-based (gene) newborn screening. The DNA is stored only because DNA is present in the blood cells. No purified DNA is stored. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">The pituitary is often called the <span style="color: #d33131; font-family: 'Times New Roman',Times,serif;">‘master’ gland. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">It has an anterior and posterior lobe.
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Pituitary disorders: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">The <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">anterior <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> pituitary produces growth hormone (GH), luteinizing hormone (LH), follicle stimulating hormone (FSH), adrenocorticotropic hormone (ACTH), thyroid stimulating hormone (TSH), and prolactin hormone (PL).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">The <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">posterior <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> pituitary produces oxytocin and stores arginine vasopressin or antidiuretic hormone (ADH), which is produced in the hypothalamus. The anterior lobe of the pituitary regulates growth, sexual development/reproduction and metabolic activity.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Growth hormone deficiency <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Precocious puberty
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Disorders of the anterior pituitary: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Deficiency results in poor growth, short stature. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Boys are evaluated more than girls. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Why? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> It may result from tumor, infection, and radiation but in 75% no cause is found.
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Growth Hormone Deficiency: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pathology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">The hypothalamus releases growth hormone-releasing hormone which stimulates the production of growth hormone. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">In growth hormone deficiency the pituitary is unable to respond.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clinical manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Increased fat in trunk area <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Child-like face, prominent forehead <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">High-pitched voice <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hypoglycemia <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Micropenis, small testes in males <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Delayed sexual maturity <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Delayed dentition

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Growth chart *meticulous measurements <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Radiographic bone studies <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">MRI <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Baseline blood testing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">2-3 provocative tests in which growth hormone stimulate is given

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Subcutaneous growth hormone injection 6-7 days a week until adult height <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Side effects- slipped femoral epiphysis, pseudotumor, edema, sodium retention

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Delayed growth and development <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Disturbed body image <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Knowledge deficit

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Outcomes/planning/teaching: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family teaching regarding medication administration and cost <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Promote positive body image <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Lifestyle changes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Prepare to choose sports/ activities that do not have height requirements <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Children should dress in clothing that fits their age and not size <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Counseling resources

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*The nurse fills the role of teacher, coordinator, advocate*

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Growth Hormone Deficiency:

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rachel is adorable. She is six years old. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">What are some of the things you note or are noted by her parents to be characteristics of growth hormone deficiency? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">What do her parents state was the hardest part of this process for themselves? For Rachel? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">What were some of the definitive tests used to make this diagnosis? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">What is the treatment?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Caucasian females breast development before age 7-8, before 6-7 in AA females <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Testicular enlargement in boys before age 9 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*4-10xs more common in girls and AA <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cause in girls idiopathic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cause boys more likely CNS lesion
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Precocious puberty: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Accelerated growth rate <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Advanced bone age <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Evidence of secondary sexual characteristics <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Acne <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Body odor <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Behavioral changes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Psychosocial development normal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mood swings

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Complete history, Tanner staging <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Exposures to exogenous hormones <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">CNS trauma or infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family history of pubertal development <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hormone levels LH, FSH, estradiol or testosterone <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">CT or MRI to rule out CNS lesion

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">GnRH analogs, initially will stimulate gonadotrophin release then will suppress ('flare'). Can be given as an injection every 3-4 weeks, a subcutaneous injection daily, a intranasal 2-3 times a day or a histrelin implant. Secondary sexual development will stabilize or regress. When therapy is discontinued puberty will resume. Very expensive.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Precocious puberty:

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20px;">**Disorders of the posterior pituitary:** <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20px;">Disorders are related to a deficiency or excess of vasopressin or antidiuretic hormone (ADH)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20px;">Diabetes insipidus: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20px;">A deficiency of antidiuretic hormone (ADH) <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20px;">Mnemonic - I want a sip of water!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Disorder of water regulation <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">ADH is suppose to concentrate the urine by stimulating reabsorption of water in the renal collecting tubules <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">When this does not happen there are large amounts of diluted urine <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Often seen in children with head trauma, cranial surgery or surgery in the pituitary region, infection, or genetics <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">May be transient or permanent

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Infants – FTT (weight loss, dehydration, fevers, poor growth, vomiting, constipation) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Older child – polyuria, polydipsia, enuresis <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Can have output from a few to 18 liters of urine a day, that's nine 2 liter coke bottles a day!

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">History <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">First morning urine to check for osmolarity, specific gravity and sodium, will be dilute <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Caution* Child may can become hypernatremic and at risk for a seizure when with holding fluids* <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Extended urine screens – requires close monitoring of I&O, weight, vitals, hydration <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Desmopressin (DDAVP) – long acting vasopressin analog (intranasally/orally) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Nurses will teach regarding fluid intake and urine output, daily weights, keeping a journal

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Diabetes Insipidus: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">media type="youtube" key="J0YoJ0xKymY?version=3" height="408" width="546"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22px;">Syndrome of Inappropriate Antidiuretic Hormone (SIADH):

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">While Diabetes Insipidus involves too little antidiuretic hormone (ADH), SIADH results from too much ADH. <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">This can be caused by infections, tumors, trauma, pulmonary disorders or chemotherapy <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Mnemonic - See I Am Drowning Here ...too much water!

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Excessive ADH leads to too much water retention; this leads to water intoxication <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Water intoxication = hyponatremia, edema, elevated blood pressure, distended jugular veins, lung crackles, <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">weight gain, fluid and electrolyte imbalance, decreased urine output

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22px;">Treatment includes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Fluid management <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Medications <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Treatment of the causative factors

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22px;">Nursing Care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Maintain electrolyte imbalances <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Monitor vital signs, <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Monitor Intake and output, note urine osmolarity, specific gravity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Monitor serum sodium <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Monitor level of consciousness (LOC), headaches, seizure activity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Daily weights <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Parental education

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 26px;">**Thyroid/Parathyroid - Hypo and Hyper**

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Low concentrations of circulating thyroid hormones T3, T4 <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Early detection prevents cretinism <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">TSH surges in first 24-48 hours so best to test after. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Newborn screening tests
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Congenital hypothyroidism (CH) **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Incidence/etiology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Females 2:1 <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Higher in Hispanics and infants with Down's syndrome, lower in AA <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Most causes are due to absent, partial, or ectopic thyroid <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Error in thyroid hormone synthesis (dyshormonogenesis)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Asymptomatic at birth <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Large posterior fontanel <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Umbilical hernia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Constipation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Prolonged jaundice

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Also: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pallor <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hypothermia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Enlarged tongue <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hypotonia, hypoactivity <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Feeding difficulties <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Delayed mental responsiveness <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cool, dry, scaly skin <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Swollen eyelids

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.280000686645508px;">Mandatory Newborn testing <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> (See endocrinology rounds first page) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">If initial positive will have a second test <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Persistent elevated TSH (thyroid stimulating hormone) indicates CH <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Some will take x-ray of knee to assess previous in utero growth retardation

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Treatment: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.280000686645508px;">Thyroid replacement - L-thyroxine (synthroid) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> 10-15 mcg/kg/day <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Checked frequently (2 weeks) until dosage therapeutic <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Goal to keep T4 in upper half and TSH in normal range <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lifelong replacement necessary

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Nursing Management/Teaching: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Growth closely monitored <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Blood tests every 2-4 weeks then every 3-4 months the first years of life. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Adolescence checked every 6-12 months <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reaassure mother she did nothing wrong <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Since infants are often asymptomatic urgency must be communicated <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Developmental screening <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Educate parents that soy milk and iron can interfere with absorption <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Crush pill, mix with breast milk or formula, make paste and place on tongue, follow with bottle

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Recognized after age 2 <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Primary, secondary or tertiary <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Primary caused by autoimmune chronic lymphocytic thyroiditis (Hashimoto's thyroiditis) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Childhood and adolescence - more in girls, diabetes type1, Downs syndrome <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Secondary and tertiary are related to pituitary or hypothalmic dysfunction
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Acquired Hypothyroidism: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Pathophysiology: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 15.600000381469727px;">Antibodies are developed against thyroid gland, it becomes inflamed and destroyed <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">T4 levels decrease and TSH increases

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">TSH, T4, free T4, Confirmation of thyroiditis with serum thyroid antibodies

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Replacing thyroid hormone with L-thyroxine doasge based on weight <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">***Must be careful child or adolescent may experience side effects of hyperthyroidism if restoration too rapid*** <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Symptoms of hyperthyroidism > agressive behavior, deterioration in school, increased intracranial pressure <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">So small dose and titrate up to euthyroid

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Hypothyroidism:

media type="youtube" key="pH1z1JQwPjA?version=3" height="439" width="588"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Baby Gabriella is just 2 weeks old. Her second newborn testing is positive for Hypothyroidism. Her parents are upset. They feel like they have already been through a lot, since she had to stay in the nursery under bili-lights because of her jaundice. She also has an umbilical hernia which they worried about and now this! They have been looking up the deficiency on the internet and want to know if she has cretinism.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Does she have cretinism? If not why?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Explain to the parents what causes hypothyroidism.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">What medicine will she take and why?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">What is a good way to administer this with an infant?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Does anything affect the absorption of the medicine?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">What are some nursing diagnoses, interventions and outcomes?

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Gabriella was born with hypothyroidism but it can also be aquired. Hashimoto's thyroiditis is an autoimmune response. The gland becomes inflamed and is destroyed. Symptoms include fatigue, weakness, constipation and dry skin. Some children may have a goiter. It can be silent with growth delays and delayed teeth eruption. Treatment is replacement of the hormone slowly to avoid a thyroid crisis.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rare before age 10. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">More frequent in girls age 11-15. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">60% family history <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pathophysiology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Antibodies formed against antigens in the thyroid gland, orbital tissue and dermis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Antibodies mimic action of TSH causing gland to inappropriately produce thyroid hormone <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Goiter present
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 23.399999618530273px;">Hyperthyroidism: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Clinical Manifestations: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">May be overlooked initially <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> > emotional lability, insomnia, increased growth, warm moist skin, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">growth patterns may change > weight loss, excellent appetite, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Also > fine tremors, opthalmic changes, heat intolerance, tachycardia <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Mistaken for ADHD

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Serum thyroid tests <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">TSH suppressed <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">T3, T4 elevated

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Difficult, chronic <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Anti-thyroid medication <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> - propylthiouracil (PTU), methimazole (MTZ, Tapazole), blocks synthesis of T3, T4 <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">11-22% have side effects must be discontinued (rash, leukopenia, arthalgia, hair loss, lupus-like symptoms, hepatitis)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Beta-adrenergic blockers <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">propranolol (Inderal) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> relieve tachycardia, restlessness, tremors

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Radioactive iodine therapy (RAI) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> for over 15 years, tissue destruction in 6-18 weeks, hypothyroidism may occur

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Thyroidectomy <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> - noncompliant caregiver or failed other options <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Spontaneous remission may occur 25%

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Nursing Management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Teaching about disease <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treatment options <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Routine blood tests <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Medications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Side effects <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Light weight clothing <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Low stress, low pressure <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Alert school if parents wish <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">May help monitor behavior, vitals, symptoms

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Hyperthyroidism:

media type="youtube" key="-Rit9veaKUA?version=3" height="408" width="546"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">This young lady talks about her thyroid levels being low when she was hyperthyroid at age 13. She is referring to her TSH levels were low due to the overabundance of T3 and T4. She then went into remission until she is 21. Then she describes her hypothyroid episode which when treated make her experience hyperthyroid symptoms again. Interesting video.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Hypoparathyroidism: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rare <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">May result from congenital disorders (DiGeorge Syndrome), surgical removal of parathyroids, destruction of parathyroid from Wilson's disease or hemachromatosis or medications.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs and Symptoms: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Life threatening hypocalcemia (tetany and convulsions) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hyperirritability, muscle rigidity, seizures, vomiting, abdominal distention, apneic episodes, intermittent cyanosis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Muscle pain, cramps <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Positive <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Chvostek sign <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> (spasm of facial muscles after tapping facial nerve) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Positive <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 18.59000015258789px;">Trousseau's sign

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Nursing Management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Access and maintain airway, breathing and circulation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Replace Calcium <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Educate parents

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hypocalcemia - Positive Chvostek and Trousseau's signs

media type="youtube" key="hOzOCNCfa_Y" width="560" height="315" <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hyperparathyroidism: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rare <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Result of adenoma <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Secondary to kidney disease (unable to reabsorb calcium)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs and symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Bone pain <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Kidney stones <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pathologic bone fractures <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hypercalcemia - muscle weakness, peptic ulcer disease, fatigue, volume displacement, mental disturbance <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Diagnosed by elevated serum calcium and elevated parathyroid hormone (PTH)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Nursing management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Fluid and electrolyte monitoring <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Surgery support <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Airway maintenance around trachea due to surgery area <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs and symptoms of infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Calcium supplementation after surgery

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">media type="youtube" key="IXKWpeIinb4" width="560" height="315"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 13pt;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Hockenberry, M. J. (2009). Chapter 29: The child with endocrine dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (2009 ed., pp. 1023-1059). St. Louis, MO: Mosby Elsevier.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Videos:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Dr. Jean Dussault Hypothyroidism http://youtu.be/pH1z1JQwPjA

Hyperthyroidism by Kellbell117 http://youtu.be/-Rit9veaKUA

Hypocalcemia by Larry Mellick http://youtu.be/hOzOCNCfa_Y

Hypercalcemia by theedexitvideo http://youtu.be/IXKWpeIinb4 <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 13pt;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Hockenberry, M. J. (2009). Chapter 29: The child with endocrine dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (2009 ed., pp. 1023-1059). St. Louis, MO: Mosby Elsevier.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Videos: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Endocrine System http://youtu.be/-S_vQZDH9hY

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Growth hormone deficiency by the Magic Foundation http://youtu.be/SAljS-uqoh8

Precocious Puberty by Akron Children's Hospital http://youtu.be/QPV7pnlDOAA

Diabetes Insipidus by isadoraseventeen http://youtu.be/J0YoJ0xKymY