Chapter 18 | Endocrine Disorders 429
appearance or appearing to be younger than actual age, delayed puberty during adolescent period, and a high-pitched voice. Diagnostic Testing ● Thorough review of growth plots on a growth chart deter- mines the rate of growth per year; special attention is given to those children whose growth is less than the third percentile. ● Biological parental heights are calculated to determine the midparental height of the parents or the average. This is used as an estimate only. ● Bone age x-ray of the left hand and wrist is used to determine the actual age of the bones in comparison with the child’s actual (chronological) age. Bone age greater than 2 stand- ard deviations (SD) below normal merits further evaluation (Escobar & Perez-Garcia, 2021). ● Magnetic resonance imaging (MRI) of the head, with a focus on the pituitary gland, is used to look for abnormalities or absence of the gland. ● Baseline blood tests include cortisol, complete blood cell count, and electrolytes. ● Provocative GH testing—this test uses certain medications that stimulate the pituitary gland to make GH (Savgon-Gurol, 2021).
Neck ● Assess neck for the presence of any enlarged areas, nodules, or glands. Muscles ● Assess strength and muscle tone. Note excess fat accumulation or decrease in muscle mass. Facial Characteristics ● Assess the face for any unusual facial features such as a protu- berant tongue, bulging of the eyes, excessive hair growth, or excessive roundness of the face.
HYPOPITUITARISM/ PANHYPOPITUITARISM
Hypopituitarism/panhypopituitarism is a condition in which one or more hormones secreted by the pituitary gland are defi- cient. GH is the most delicate of all the six hormones produced by the pituitary gland and is the first to become insufficient when the gland is damaged. This can occur as a result of trauma to the head during delivery or later in life, tumors of the hypo- thalamus or pituitary, infectious disease in the central nervous system (CNS), chemotherapy, radiation, surgical resection, and congenital syndromes. Growth Hormone Deficiency Children with growth hormone deficiency (GHD) have a clini- cal presentation of delayed growth of less than 2 inches (3 to 4 cm) per year. This is monitored by plotting serial growth points on the growth chart for his or her age and sex. Children with GHD have a consistent declination of growth measurements on the growth chart over time and a high weight-to-height ratio with increased abdominal fat. Infants may present with a delay in closure of the anterior fontanel.
CRITICAL COMPONENT Growth Hormone Secretion
GH is secreted in pulsatile spurts during a 24-hour period, not constantly. A single laboratory measurement of GH is not indicative of GHD.
● Insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 to test for GHD (Savgon-Gurol, 2021) ● Karyotype in girls to rule out Turner syndrome (Escobar & Perez-Garcia, 2021) ● Thyroid function test to detect hypothyroidism ● ACTH and cortisol levels to detect the presence of other hormone deficiencies ● Urine creatinine, pH, specific gravity, blood urea nitrogen (BUN), and electrolytes to detect the possibility of short stat- ure being caused by chronic renal failure ● Complete blood cell count and sedimentation rate to rule out any inflammatory bowel disease ● Antigliadin antibodies to screen for celiac disease Nursing Interventions ● Careful measurement and documentation of growth on the child’s age- and sex-appropriate growth chart, noting declin- ing trends in growth patterns over a 6-month to 1-year period ● Assess for psychosocial clues that the child or parents are hav- ing trouble dealing with the child’s stature. Examples may include the following: ● Child does not want to be involved in team activities for fear of being bullied or fear that he or she cannot physically play the games/sports.
CLINICAL JUDGMENT Congenital Hypopituitarism
Frequent or recurrent hypoglycemia, prolonged jaundice, small penis/testes, lethargy, feeding problems, and excretion of excessive amounts of urine in the neonatal period may indicate congenital hypopituitarism. Infants with this condition are prescribed GH replacement therapy immediately to help regulate blood sugar levels. This type of neonatal hypoglycemia can be fatal if not treated immediately upon diagnosis. These infants undergo further testing to detect other possible pituitary hormone deficiencies that need treatment. Other common hormone deficiencies are hypothyroidism, adrenocorticotropic hormone deficiency, and ADH deficiency (Bosch i Ara, Katugampola, & Dattani, 2021).
Other characteristics of children with GHD may include delayed dental eruption, decreased muscle mass, cherubic-like
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