Beta cells in Pancreas produce a hormone called Insulin. Insulin is a an anabolic hormone (Helps to make body stores of carbohydrates, fat and proteins) which regulates the sugar levels within the normal range (70-180 mg/dl).

Diabetes is a condition associated with high blood sugars. This may happen due to –
– Insulin deficiency / absence
– Insulin Resistance (Insulin not able to act)

– Type 1 Diabetes – Insulin deficiency / Absence
– Type 2 Diabetes – Associated with Insulin Resistance
– Monogenic Diabetes

– Cause – Most commonly, insulin deficiency happens due to autoimmunity (Our immunity is supposed to attach germs / things foreign to our body ; In this case, mistakenly, body’s own beta cells are attacked) against beta cells of pancreas

– Most common symptoms –
– Increased thirst
– increased urination
– increased hunger but weight loss present

Treatment –
– Insulin replacement therapy

Type 2 Diabetes is most common in adults but these days, due to obesity, unhealthy lifestyle like increased screentime, sedentary lifestyle, junk food intake, adolescents are also developing Insulin Resistance leading to Type 2 Diabetes.

As per Studies done on Type 2 Diabetes in young, this form is more aggressive in its course in children as compared to the course of disease when adults get it.

Most common signs and symptoms –
– Obesity
– Acanthosis nigricans – Blackening of skin at the nape of neck, armpits, groins (Marker of Insulin Resistance)
– Slower more insidious onset of increased urination, thirst and hunger
– Poorly healing wounds
– Fatigue

Treatment – Lifestyle changes, Oral drugs (Insulin sensitisers), May also need Insulin replacement therapy

Genes are our body’s smallest blueprint which decide how the body organs organs will function.

Multiple genes regulate how insulin would form and how it will work in the body. If there is a single gene affected which affects insulin action, its called Monogenic Diabetes.

This is the Third type of Diabetes which is rare but an experienced Pediatric Endocrinologist can identify who has this.

This type may respond to Insulin or to tablets. These kids may also have other issues like bone, thyroid, liver, genitourinary, hearing affections based on type of gene involved.

Treatment – Insulin or Oral drugs may work based on type of genetic mutation

– Poor scholastic performance
– Increased Fatiguability
– Poorly healing wounds

– Increased occurence of infections

– Microvascular complications 
– Diabetic Nephropathy (Kidney Affection)
– Diabetic Retinopathy (Retina is the main sensory part of eye, responsible for vision)
– Diabetic Neuropathy

– Macrovascular complications – Increased risk of blood vessels of heart, brain, nervous system, limbs being affected

Some children require certain drugs during treatment of another disease which can cause high sugars as a side effect. Most common of these drugs are – Steroids and L- Asparaginase.

These forms need sugars to be monitored and may need oral drugs or insulin therapy

Isme illustrations daalna hai kahin kahin

Some ideas for illustrations / pictures
–
1st question ke saath –
Photo of pancreas

2nd question ke saath – photo of machine checking high blood sugar

Type 1 diabetes – put picture of glucometer (machine to check sugar, insulin pens)

With what are genes question, photo from internet coming for genes

Complications waale question pe – some photo from net for complications of diabetes

Growth disorders –

Growth is a common english word which suggests how the body parts are increasing in size in pediatrics. Growth of a child is like a “MIRROR OF HIS / HER OVERALL HEALTH”.

Normal growth is average growth. “UNDERGROWTH” as well as “OVERGROWTH” is abnormal.

A child grows based on a number of factors put in order below from IN UTERO (when in mother’s womb) period till achievement of FINAL ADULT HEIGHT which mainly include –

– In Utero period – Maternal and Placetal factors ; Any fetal factors restricting growth

– Birth weight

– Childhood – Good nutrition, Tender loving care, Hormones in balance

– Adolescence – Good nutrition, Good mental health, Age at puberty, Hormones in Balance

– Factors which may act at any stage – Any chronic illness, Chronic drug intake / unlabelled medications containing steroids, Disorders with abnormal bone development (Skeletal Dysplasias)

– Mid Parental Height – Genetics decides how a child grows. Mid parental height is a summated height calculated from mother’s and father’s height. Kids of short parents are short and tall parents are tall.

– Thyroid hormone
– Growth Hormone
– Sex steroids at puberty
– Any chronic hormonal imbalances like vitamin D, calcium, adrenal disorders, tubular disorders may affect growth

A Pediatric Endocrinologist assesses growth subjectively and objectively.

Subjective assessment to answer below –
– Age at onset of short stature ?
– Is the child outgrowing clothes / shoes ?
– Association with puberty ?
– Any systemic diseases and signs and symptoms of any hormonal imbalance ?

Objective assessment –

– Measure Weight, Height, Head size
– BMI (Calculated measure which includes both weight and height together)
– Body proportions, Limb proportions
– Plotting above on Indian Growth charts which informs if child is short for their age and if they are short for parents’ height

Every child irrespective of having any medical issues should undergo Growth and Puberty monitoring as per IAP (Indian Academy of Pediatrics) guidelines. At any age, if there is a deviation from normal patterns, a child needs evaluation.

The height of a child increases by a certain defined amount every year. With late attention, that WINDOW OF OPPORTUNITY for GOOD GROWTH is lost.
Example – if a child is not growing since 3 years of age and is presenting for the first time for this complaint at 8 years age, the child has lost 5 years of growth which can’t be covered completely on correcting the issue responsible for under growth.

– Poor nutrition

– Severe systemic diseases / chronic disorders / Chronic medications

– Psychosocial short stature

– Babies born with a birth weight of < 2.5 kg may or may not catch up to Parents’ potential of height gain

–

– Hormonal disorders —

A) Hypothyroidism (Low function thyroid gland)

B) Growth hormone disorders – It is a hormone secreted by Pituitary gland. This hormone may be deficient or may not be able to act efficiently. Use of growth hormone therapy is approved by FDA (Food and Drug Administration) for following indications currently (A Pediatric Endocrinologist has the expertise to diagnose these disorders) —
– Turner Syndrome
– Noonan Syndrome
– Small babies
– Russel silver syndrome
– Prader Willi syndrome
– Chronic Kidney disease
– Idiopathic short stature (No cause of short stature could be found)
– Small bowel syndrome
– SHOX gene deletion
– Child / Adult growth hormone deficiency
– Except above, there are a number of indications, which are not approved for GH therapy but academic literature and case reports have witnessed good response of height to GH therapy

C) Pseudohypoparathyrodisim – It is a disorder which is associated with abnormal formation / growth of bones and resistance to certain hormones in body.

D) Diabetes

E) Adrenal excess syndromes

F) Hypopituitarism (Congenital, Acquired)

– Bone disorders – Skeletal dysplasias, Rickets

A Pediatric Endocrinologist has special experience in Growth monitoring, use of growth charts, prediction of adult height, know what is a normal variant of short stature. As enumerated above, multiple causes affect growth. To understand treatment of which one out of above multiple causes will help a child needs a Pediatric Endocrinologist’s advise.

Low sugars (Hypoglycemia) –

Low sugar levels are different at different times of life.
Low sugars are defined as a sugar of < 45 mg/dl in newborns and <54 mg/dl in bigger children.

Sugar, fatty acids, ketones are the substances in our blood which are like FUEL / FOOD for brain. A child’s brain is developing till 5 years of age. If a developing by any factors like low oxygen, seizures, low sugars, there may be permanent effects in the form of delayed development, vision defects, seizure disorder requiring anti epileptic drugs, suboptimal scholastic performance.
The injuries on a developing brain do not recover or normalise by healing unlike other organs in body, hence causing permanent issues.

Low sugars maybe cause by endocrine issues like –
– High insulin (Congenital / Acquired)
– Low adrenal hormones
– Low thyroid / growth hormone
– Multiple pituitary hormone deficiency

Metabolic issues like –
– Gluconeogenic defects
– Ketogenic defects
– Ketolytic defects
– Glycogen storage disorders
– Galactosemia
– Fatty Acid Oxidation defects
– Liver diseases
– Other rare Inborn errors of metabolism

– Mitochondrial / other rare genetic disorders

– Critical sampling means blood samples taken at a sugar of less than 50. At this sugar, there are a number of defence mechanisms in body which try to normalise sugar levels.
– we see these reports and are able to compare these levels of metabolites to the normal expected levels and understand what is the exact abnormality causing low sugar

– If this critical sampling is missed, then any blood samples taken during normal sugars may also be sent for workup but it may or may not be able to catch the exact abnormality. In such a scenario, the way forward is by fasting a child under supervision to take all blood samples when sugar is < 50 mg/dl. This procedure is risky, hence needs an experienced Pediatric Endocrinologist to do it. This is called Diagnostic Controlled Fasting test.

Majority of these kids are symptomatic since newborn period / infancy. Genetic testing is of utmost importance. Most of these cases can be medically managed.

Removing pancreas to remove all source of insulin is not required as it can put the child at risk of lifelong Diabetes and digestive issues. Decision on medical management should be taken by an experienced Pediatric Endocrinologist and if medically manageable, then surgical management should not be thought of.

Above group of diseases are called CHI (Congenital Hyperinsulinism of Infancy) / PHHI (Persistent Hyoerinsulinemic Hypoglycemia of Infancy). When managed with expertise, they have good developmental outcome.

Thyroid gland is an Endocrine gland present in the neck with 2 main lobes - right and left lobe and an isthmus.

Thyroid gland forms thyroxine hormone which has different functions in the body. These include -

- Controls metabolism
- Regulates heart rate and Blood pressure
- Controls speed at which food moves through digestive system
- Regulates body temperature
- Regulates Menstrual cycles
- Controls skin, hair and nail growth
- Has interaction with other hormones in body
- Regulates growth (weight and height)
- Aids in proper neurodevelopment

Signs of symptoms of thyroid disease -

Low thyroid function with -

- Slow growth, Short height, short limbs
- Swollen face with coarse features
- Dry coarse skin
- Dry brittle hair
- Hoarse voice
- Delayed dentition
- Delayed development in Congenital Hypothyroidism
- Slowness in activity, sluggishness
- Cold intolerance
- Poor muscle tone
- Constipation
- Menstrual irregularity
- Delayed puberty
- Goitre (Enlarged Thyroid)
- Impaired school performance

High thyroid function with issues like -

- Goitre (Swelling of thyroid gland)
- Palpitations, nervousness, anxiety, restlessness
- Trouble concentrating in studies at school
- Feeling too hot
- Tremors
- Prominent eyes
- Blood pressure mat be high
- Frequent passage of stools

There has to be a high index of suspicion for any thyroid disorder. Based on it, a thyroid function test is done (Best done in morning hours). Sometimes, we may also need to tests like Sonography of thyroid gland, antibodies like TPO antibodies, TRAB antibodies which attack thyroid gland and cause hormonal imbalance.

On low thyroid disease, we give thyroxine hormone as a tablet. In high thyroid disease, we give a tablet to decrease thyroxine levels in blood.

Rarely we may also need treatment options like Radioiodine ablation of thyroid gland, thyroidectomy (Surgical removal of thyroid gland). In high thyroid disease, your child may also need to be on medications like Propranolol.

- Bones are formed of organic matrix and inorganic minerals. Both the components of bones need to be appropriately formed for proper bone strength.

- The organic matrix of bone, also known as osteoid, is the unmineralized, organic component of bone tissue, primarily composed of type I collagen, non-collagenous proteins and water, providing flexibility and elasticity.

- Inorganic Components:
1) Hydroxyapatite: The primary mineral component, providing bone's hardness and rigidity.
2) Calcium: A major mineral in bone, forming calcium hydroxyapatite crystals.
3) Phosphorus: Another key mineral, along with calcium, in the formation of hydroxyapatite.
4) Magnesium, Potassium, Sodium, and Sulfur: Other minerals present in bone, contributing to its structure and function.

- 1) Hormones associated with acquisition and balance of Calcium and phosphorus in body (Main minerals responsible for mineral bone component) -
A) Vitamin D - It's storage form is 25 OH- Vitamin D. Active form formed the storage form is 1,25 OH Vitamin D. This storage and conversion to active form is done in liver and kidney respectively.

B) Parathyroid hormone / Parathormone - It maintains calcium levels in body and has role in formation of active form of Vitamin D

2) Sex steroids at Puberty - After attainment of puberty, sex steroid (Estrogen in girls and Testosterone in boys) levels become pubertal and help in achievement of peal bone mass. Any issues with puberty, it's onset or low formation of Sex steroids may also affect bones.

- Chronic systemic diseases like malabsorption, chronic liver diseases like Wilson disease, chronic kidney disease, Celiac disease, or other systemic disorders may affect bones
- Chronic inflammatory disorders
- Malnutrition
- Other chronic disorders
- Disorders with chronic immobilisation of child like neurological disorders
- Any drug induced osteoporosis / weak bones state like chronic Steroids exposure

A Skilled Pediatric Endocrinologist takes a meticulous history, examination in depth to know the exact cause of bone issues.

- Issues like Bone pains, Bony deformities like knock knees, bow legs, windswept deformity, Other Bony deformities, Abnormally formed bones (Skeletal dysplasias), Recurrent fractures, Lower back pain due to vertebral fractures

- Blood tests like Calcium, phosphorus, vitamin d, PTH hormone levels
- X rays of various bones maybe ordered
- DEXA scan if the case requires