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Management is similar to hypernatremic dehydration with initial reexpansion of intravascular volume, then repletion of maintenance over 48 hours Syndrome of Inappropriate Antidiuretic Hormone Secretion Associated with bacterial meningitis (50%), positive pressure ventilation (20%), Rocky Mountain spotted fever (70%), and numerous other illnesses For severe lethargy, seizure, or coma administer 3% saline emergently (3 mL/kg every 10 to 20 minutes as needed), consider furosemide, initiate antiepileptic drugs if indicated, and treat underlying cause Hyperparathyroidism Uncommon in children Family history is important as hyperparathyroidism is associated with MEN I, II and being an infant born to a mother with hypoparathyroidism Demineralization and bone resorption seen on x-ray Hypoparathyroidism Rare in children but tends to be associated with familial autoimmune syndromes, immunologic deficiencies, or iatrogenic etiologies Rickets Rickets is caused by inadequate dietary intake of vitamin D; incidence is decreasing as increased awareness and increased supplementation in food Failure of calcification affects those parts of the skeleton that are growing most rapidly or that are under stress; a clinical diagnosis that is confirmed by radiology Thyroid Storm Thyroid storm is the fulminant intensification of hyperthyroid state Precipitated by intercurrent infection, trauma, or after subtotal thyroidectomy with an inadequately prepared patient Presence of high fever (often to 105.8°F [41°C]) is primary distinguishing feature of thyroid storm from hyperthyroidism Marked increase in cardiac workload may result in high-output heart failure, systemic hypotension, and pulmonary edema rather than classic systemic hypertension Neonatal Thyrotoxicosis Neonatal thyrotoxicosis is a life-threatening condition found in 1% to 5% of infants born to mothers with history of hyperthyroidism; mother’s thyroid disease does not have to be active during pregnancy Congenital Hypothyroidism Increased incidence of ED visits for congenital hypothyroidism now that infants are being routinely screened at birth Untreated disease may result in impairment of neurologic development See Table 89.1 TABLE 89.1 SUMMARY OF CLINICAL FEATURES, INVESTIGATIONS, AND INITIAL TREATMENT OF PEDIATRIC ENDOCRINE EMERGENCIES Condition Major clinical features Diabetic ketoacidosis Polyuria, polydipsia, Blood glucose, pH dehydration, ketotic breath, hyperpnea, nausea, vomiting, abdominal pain, coma 0.9% saline 10 mL/kg in first 1–2 hrs IV; insulin infusion 0.1 Unit/kg/hr; later, may need KAcetate 10–60 mEq/L and KPhos 10–20 mEq/L Hypoglycemia Older child : hunger, sweatiness, dizziness, convulsions, coma Neonate : apnea, hypotonia, hypothermia, irritability, tremor, convulsions Ambiguous genitalia in females; poor feeding, weight loss, irritability, vomiting, dehydration Nausea, vomiting, abdominal pain, weakness, malaise, hypotension, dehydration, hyperpigmentation 25% dextrose 1–2 mL/kg IV bolus or 10% dextrose 5–10 mg/kg/min IV infusion, glucagon 0.5–1 mg IM stat (if hyperinsulinism) Congenital adrenal hyperplasia Adrenal insufficiency Hypercalcemia Headache, (hyperparathyroidism) irritability, anorexia, constipation, polyuria, polydipsia, dehydration, hypertension Urgent investigations Blood glucose Serum for growth hormone, cortisol, insulin; first-voided urine for organic acids and toxin screen Initial treatment Plasma sodium, 0.9% saline 20 potassium, glucose, mL/kg in first 17hour IV; hydroxyprogesterone; hydrocortisone karyotype and pelvic 25 mg IV stat ultrasound (neonatal dose) Plasma sodium, Hydrocortisone potassium, glucose, 100 mg IV stat; cortisol, and ACTH 10% dextrose in (for retrospective 0.9% saline 20 confirmation of mL/kg in first diagnosis) hour Plasma calcium, phosphate 0.9% saline at two to three times maintenance rate; furosemide mg/kg ...TABLE 89.1 SUMMARY OF CLINICAL FEATURES, INVESTIGATIONS, AND INITIAL TREATMENT OF PEDIATRIC ENDOCRINE EMERGENCIES Condition Major clinical features Diabetic ketoacidosis Polyuria,