|Year : 2020 | Volume
| Issue : 5 | Page : 11-13
Care of pediatric and adolescent endocrine disorders during COVID-19 pandemic
Inderpal Singh Kochar1, Smita Ramachandran1, Gitanjali Kochar2
1 Department of Pediatric and Adolescent Endocrinology, Indraprastha Apollo Hospital, Delhi, India
2 Department of Medicine, Indraprastha Apollo Hospital, Delhi, India
|Date of Submission||24-Jun-2020|
|Date of Acceptance||28-Jul-2020|
|Date of Web Publication||07-Aug-2020|
Inderpal Singh Kochar
Indraprastha Apollo Hospital, Delhi
Source of Support: None, Conflict of Interest: None
Coronavirus pandemic cases are increasing worldwide, including that in India. Pediatric cases are also increasing, although children may have more of mild manifestation of the disease and are recovering fast. Children with endocrine disorders are considered at a higher risk of contracting the virus due to their immunocompromised status. Children with diabetes, adrenal insufficiency, and thyroid disorders are the usual conditions for which they are on long-term treatment and need to be monitored closely. The article gives an outline of management of children with endocrine disorders during the current pandemic.
Keywords: COVID-19, obesity, thyroid, Type 1 diabetes, Vitamin D
|How to cite this article:|
Kochar IS, Ramachandran S, Kochar G. Care of pediatric and adolescent endocrine disorders during COVID-19 pandemic. Apollo Med 2020;17, Suppl S1:11-3
COVID-19 pandemic has been increasing exponentially. Most patients affected are in the older age groups, and involvement of those below 18 years is much lower. The severity of COVID-19 has been classified as being asymptomatic, mild, moderate, severe, and critical. The former three forms comprise over 90% of all childhood cases. Severe and critical cases have been seen in 5.9%, as compared to 18.5% in adults. The possible explanations for lower number and milder infections in children and young adults include lower exposure to virions, isolation at home, and lesser exposure to pollution and cigarette smoke. Viral co-infection may be important in potentially leading to limited replication of the COVID-2 by direct virus-to-virus interaction and competition. In addition, the distribution, maturation, and functioning of viral receptors such as angiotensin-converting enzyme (ACE) 2 may be important in age-dependent susceptibility to severe COVID-19.
| Covid-19 in Pediatric Population|| |
The common clinical features reported in critically ill patients include fever (98%), cough (77%), dyspnea (63%), malaise (35%), myalgia, headache, nausea, vomiting, and diarrhea. Young children often present with abdominal pain, diarrhea, and shock. Post-COVID immunologically mediated hyperinflammatory multisystem involvement in children (termed as an atypical Kawasaki disease), toxic shock syndrome, and macrophage activation syndrome has been observed in occasional cases.
| Covid and Pediatric Endocrine Disorders|| |
Children with well-managed endocrine conditions do not seem to be at increased risk of getting infected or becoming severely ill with COVID-19. The illness generally has a milder course.
| Covid and Diabetes|| |
COVID-19 pandemic recommendations in most countries include people with diabetes within the risk population. The principles of management (modified from ISPAD guidelines) include the following:
- More frequent blood glucose and ketone (blood or urine) monitoring. Aim for a blood glucose level between 4 and 10 mmol/L (70–180 mg/dL) and blood ketones below 0.6 mmol/L when the child is ill.
Actrapid and all newer insulins should be clear as water and not cloudy or lumpy. Neutral protamine Hagedorn will be cloudy but not lumpy. Insulin will not be effective if it is frozen or kept in direct sunlight and heat. Change vial/pen if in doubt. If there is difficulty procuring insulins, Actrapid, Humulin-R, Humalog, Novorapid, Apidra, and Fiasp can be used interchangeably as a temporary measure. Similarly, Lantus, Basalog, and Tresiba can be used as replacements.
Never Stop Insulin: If there is FEVER, insulin needs are usually higher. Monitor and maintain hydration with adequate salt and water balance.
- Treat underlying illness and reduce fever.
Urgent specialist advice with possible referral to emergency care must be obtained when:
- Fever or vomiting persists and/or weight loss continues, suggesting worsening dehydration and potential circulatory compromise
- Fruity breath odor (acetone) persists or worsens/blood ketones remain elevated >1.5 mmol/L or urine ketones remain large despite extra insulin and hydration
- The child or adolescent is becoming exhausted, confused, hyperventilating (Kussmaul breathing), or has severe abdominal pain.
| Hypoglycemia in Covid-19 Infection|| |
The principles of management include:
- Severe hypoglycemia: Low blood sugar (<70 mg/dl) with drowsiness unresponsive or seizures:
- Give injection glucagon (0.5 ml if a child weighs <25 kg or 1 ml if more than 25 kg) on lateral thigh intramuscularly or subcutaneously. Within 10–15 min, the child should regain consciousness. Check blood glucose again and give a small snack (e.g., a glass of milk or a slice of bread). If the child continues to be not responsive, hospitalize immediately
- If injection glucagon is not available at home: Take the child to hospital immediately for IV glucose injection. Do not try to force sugar water into child's mouth. While going to hospital, make a paste of Glucon-D powder with little water and rub this paste between child's gums and lips or take honey and rub it.
Prevention of hypoglycemia during illness
- Type 1 diabetes: Check blood glucose more frequently, especially if the child is not well (fever, loose stools, and vomiting). If blood glucose is consistently <100 mg/dl, decrease your Insulin doses.
| Adrenal Disorders|| |
Adrenal insufficiency during COVID-19 illness:
- If the child becomes symptomatic, increase the hydrocortisone dose, according to the general “sick-day rules” in children with adrenal insufficiency due to congenital adrenal hyperplasia (CAH), panhypopituitarism (pituitary failure), and Addison's disease.
If congenital adrenal hyperplasia on Hisone tablets:
If the child is unwell, give a stress dose of Hisone. Stress dose is usually 3–5 times the usual dose of Hisone. If the child is on Floricot also, there is no need to increase its dose. If the child seems very dull and sleepy, if his/her hands and feet are cool to touch, he/she needs immediate hydrocortisone injection and shift to the nearest hospital. Hydrocortisone is given by intramuscular or intravenous means in the dose of 25 mg (up to age 3 years) and 50 mg (3–12 years) and 100 mg (>12 years). Further dosing may be required, every 6 h, if the child continues to be unwell.
- Patients with active Cushing's syndrome are immunosuppressed and at risk of viral and other infections and should be advised to follow the guidance on social distancing and self-isolation/shielding. Rapid normalization of cortisol secretion is needed to minimize the risk of infection. Since diabetes mellitus and hypertension appear to be significant risk factors for adverse outcomes from COVID-19, especially in Cushing's syndrome, these comorbidities should be very actively managed.
Insulin, hydrocortisone, and other medications supply during the global outbreak. Adequate supplies of insulin/hydrocortisone/other medications should only be stocked for a week only, large amounts of stocking is not required.
| Covid-19 and Growth Hormone Deficiency|| |
Children who are already on growth hormone (GH) therapy and well should continue GH replacement at the same dose even if no recent insulin-like growth factor 1 level is available. If the patients prefer to pause their GH replacement or if there is a supply issue, patients can safely do so for few weeks. For the patients with suspected or confirmed COVID-19, it is advisable to stop GH if the patient requires hospital admission and restart when the patient has recovered and is asymptomatic from COVID-19. For the new patients with confirmed GH deficiency, it is advisable to delay GH initiation to avoid unnecessary travel for blood tests and to avoid starting GH without biochemical and clinical monitoring.
| Turner Syndrome Girls and Covid-19|| |
Girls with Turner syndrome with bicuspid aortic valve, dilatation of the aorta, coarctation repair, partial anomalous pulmonary venous drainage, and aortic valve replacement are not in the vulnerable group but do need to practice stringent social distancing. All the patients taking ACE inhibitors and angiotensin receptor blockers should continue to do so during the COVID-19 pandemic.
| Covid-19 and Thyroid Disorders|| |
Immunocompromised patients have a weaker immune system and thus at higher risk of severe illness from COVID-19. However, there is no evidence that patients with autoimmune thyroid disease are at greater risk of getting COVID-19 or of being more severely affected should they acquire the COVID-19 infection. Antithyroid drugs (ATDs) are not known to increase the risk of infection with COVID-19 or of developing more severe disease. A patient infected with COVID-19 can continue ATDs unless neutropenia (neutrophil count of <1.0 × 109/L) is present.
| Coronavirus (Covid-19) and Parathyroid Conditions|| |
At the moment, there is no evidence that having hypoparathyroidism alone makes increases the risk of contracting coronavirus infection. Some of these patients may have very unstable calcium levels, a weaker immune system, or other conditions which make illness more difficult to manage.
| Role of Vitamin D in Covid-19 Infection|| |
There is insufficient evidence to supplement Vitamin D for reducing the risk of COVID-19 infection, although it may decrease the severity of the disease. Vitamin D levels are very often low in the aging population, in whom COVID disease is more severe.
| Obesity|| |
Obesity is a risk factor for death from COVID-19, according to a new study from the US Centers for Disease Control and Prevention based on 99 countries and 14 states. It is considered one of the moribund conditions and has been added to many protocols as a high-risk factor. In this pandemic with the lockdown, lack of mobility and exercise tend to aggravate weight gain.
| Conclusions|| |
It is seen that well-controlled endocrine diseases are not at an increased risk of severe disease. Endocrine disorders in children are mostly managed by specialists. They should continue their practice employing telemedicine. Access to own pediatric endocrinologist is advised but may be difficult to obtain during COVID-related restrictions. The family needs clear guidance for proper management, especially during emergencies. The disease process and management modalities are still evolving, and in the coming months, we may have enough data to create disease-specific management guidelines related to COVID-19.
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Conflicts of interest
There are no conflicts of interest.