Page 56 Complete Your CE Test Online - Click Here measures to control fluid balance until the intracranial pressure is relieved. When and why does gestational diabetes insipidus occur? Gestational diabetes insipidus occurs during pregnancy when an enzyme produced by the placenta destroys the mother’s ADH[5] . Hilary and Nathan have two children. Steven, an active three year old who is “into everything” is a “real handful” his parents say. Even as a baby, Steven was “a challenge.” He awoke frequently during the night and seldom seemed to need to nap. As a toddler Steven constantly “explores” and seldom sits still. His favorite word, of course, is “no.” Hilary gave birth to a baby girl three months ago. Her ecstatic parents tell everyone what a “good” baby little Angela is. She seldom cries, sleeps through the night and naps during the day, and, as her parents describe her, is very “calm.” Nathan’s mother is concerned, however. “This baby is way too “good,” she thinks. The baby has a puffy face and droopy eyelids. Her parents attribute this to “baby fat” and “sleepiness.” Nathan’s mother believes that something is really wrong. Is Nathan’s mother right or wrong? Is little Angela simply a “good” baby or is there something more ominous going on? Little Angela is displaying behaviors that are characteristic of hypothyroidism in children. This is a common disorder that affects one in every 2,500 to 3,000 babies[12] . Timing of recognition and treatment is critical. If treatment begins before the age of three months the infant usually experiences normal growth and development. However, if the baby remains untreated beyond the age of two, irreversible mental retardation occurs. Skeletal abnormalities, however, are reversible with treatment[5] . Infant hypothyroidism (cretinism) is usually due to defective embryonic development of the thyroid gland. The next most common cause is related to an inherited enzymatic defect in the synthesis of thyroxine[5] . What aspects of Angel’s clinical manifestations indicate childhood hypothyroidism? What additional signs and symptoms would you anticipate finding on physical examination? Angela is inactive, seldom cries, and sleeps excessively. Her face is puffy and her eyelids droop. Additional signs and symptoms of childhood hypothyroidism include[5,12] : ● ● Hoarse cry. ● ● Abnormally deep tendon reflexes and hypotonic abdominal muscles. ● ● Short forehead, puffy, wide-set eyes, broad, upturned nose, and a vacant, dull facial expression. ● ● Protruding abdomen. ● ● Feeding problems. ● ● Cold, coarse, thick, and dry skin. ● ● Dry, brittle hair. ● ● Slow pulse. ● ● Below normal body temperature. ● ● Jaundice. ● ● Large, protruding tongue. Angela will require life-long thyroid hormone replacements. Doses in children are higher than in adults because children metabolize thyroid hormone much more rapidly. Initial doses are of moderate strength, but are gradually increased to attain levels adequate for life-long maintenance[5] . A word of caution about thyroid hormone replacements! Too rapid increase in dosage can lead to thyrotoxicity. Signs and symptoms include tachycardia, vomiting, hypotension, tremor, weakness, shortness of breath, cough, swollen extremities, and coma. Immediate emergency treatment is needed[5,11] . Parents should be taught to differentiate between signs and symptoms of a “good” baby and pathology. Differentiate among the various types of hypothyroidism that affect children. ● ● Congenital hypothyroidism (CH): Occurs when the thyroid gland fails to develop or function normally before birth[12] . ● ● Acquired hypothyroidism-autoimmune hypothyroidism: Occurs as the result of an autoimmune disorder called chronic lymphocytic thyroiditis (CLT). In CLT the child’s immune system “attacks” the thyroid gland, causing damage and reduced functioning. Patients who have other types of autoimmune diseases (most often insulin- dependent diabetes) are at higher risk for developing CLT. It is estimated that 20% to 30% of diabetics will develop CLT. Thus, annual screening for CLT is often a routine part of diabetic care[12] . ● ● Acquired hypothyroidism-iatrogenic hypothyroidism: Occurs in people who have had their thyroid glands surgically removed or medically destroyed[12] . Louise is preparing for oral comprehensive exams as part of her doctor of nursing science degree. One of the areas of focus is endocrinology. Her study group members are taking turns asking each other to present information as part of their preparation for these exams. Louise is asked: What is myxedema coma? What causes it? How is it treated? How should Louise respond? Myxedema coma is the most serious and dramatic complication of hypothyroidism. It often leads to death. This complication usually has a slow progression. However, stressors such as infection, trauma, exposure to cold, or heart attack can intensify hypothyroidism, causing myxedema coma to develop abruptly[5,6] . Since initial signs and symptoms of hypothyroidism can be vague and nonspecific patients may go undiagnosed for long periods of time. This can increase the possibility that a gradual development of myxedema coma may be the dramatic event that triggers diagnosis. Signs and symptoms of myxedema coma are significantly depressed respirations, decreased cardiac output, and progressively worsening cerebral hypoxia. Heart rate slows, and blood pressure drops. Patients become hypothermic and stuporous[6] . Treatment involves I.V. administration of thyroid hormones and correction of electrolyte and volume imbalances [5,6] . In order to save the patient’s life, treatment must be swift, and the patient’s condition monitored in the hospital setting. It is therefore imperative that HCPs be taught to recognize myxedema coma and to initiate immediate treatment. The day arrives for Louise to take her oral comprehensive examination. The examiners ask Louise to: ● ● Define and describe the clinical manifestations of Graves’disease. ● ● Identify risk factors that increase the risk for its development. ● ● What treatment initiatives are appropriate for Graves’disease? How do you think Louise should respond to these questions? Graves’ disease, or hyperthyroidism, is a metabolic imbalance characterized by excessive amounts of thyroid hormone in the bloodstream[5,6] . Risk factors for its development include[5,11,16] : ● ● Family history of the disease. ● ● Being female. ● ● Being over the age of 40. Only 5% of patients with hyperthyroidism are younger than 15 years of age. However in Graves’s disease specifically, incidence is highest between the ages of 30 and 40. ● ● Coexistence of other autoimmune disorders. ● ● Smoking. ● ● Pregnancy. ● ● Stress. ● ● Excessive dietary intake of iodine. Characteristic signs and symptoms of hyperthyroidism include [5,6,11] : ● ● Enlarged thyroid gland (also referred to as goiter). ● ● Exophthalmos (abnormally protruding eyes and a characteristic staring gaze). ● ● Heat intolerance. ● ● Nervousness. ● ● Inability to sit still. ● ● Weight loss even though appetite is increased. ● ● Diaphoresis. ● ● Diarrhea. ● ● Tremors. ● ● Palpitations. Hyperthyroidism affects every system of the body. Additional signs and symptoms as they relate to body systems include[5,6,11] : ● ● Cardiovascular system: Arrhythmias, tachycardia, full bounding pulse, cardiac insufficiency, and resistance to the prescribed