Welcome to our fall 2020 newsletter! As the world is bracing the second wave of COVID-19, we as pediatric and pediatric endocrine health care professionals play a role in making sure that across the globe, children’s needs in general, and the needs of children with health care conditions in particular, are cared for.
When advocacy for access to diabetes and endocrine care for children was important before COVID-19, it has become essential during this pandemic, especially for children in LMIC. Lockdowns, and travel restrictions, fear of contracting the virus, and increased financial strain on families have exacerbated access difficulties, to insulin and diabetes supplies, and to diabetes health care providers who are pulled away to serve in COVID-related health care. International transport restrictions (such as for insulin shipments), decreased international donations that many pediatric diabetes centers in LMIC depend on, and reduced governmental health care funds further jeopardize care access in the intermediate to long-term. We know of COVID-related mortality in youth with diabetes in some countries (Haiti, Bangladesh), and there may be more. Data is emerging documenting the detriments of care delay for non-COVID diseases, including higher rates of DKA and DKA severity. Let’s all do our part to advocate, educate, care for, do and disseminate research to address these access issues—during and after COVID.
In light of these significant COVID-related challenges, our newsletter is refreshing in that it brings to light some of the innovation that the pandemic has brought upon us, including in scientific exchange via virtual conferences (p1), web-based education platforms (p.2), as well as innovations that continue to take place despite the pandemic: From D-mom to Dcoach (p.3), diabetes training program in Sudan (p.4) and visiting scholars exchange program in China (p.5). ENJOY!!
The following topics are covered in this 17th edition of our Newsletter:
GPED Annual General Meeting (AGM)
Education in paediatric endocrinology during COVID-19 pandemic in Latin America
ESPE Yearbook 2020 and ESPE Connect: Global Health for the Pediatric Endocrinologist
Supporting diabetes care in children living in rural India
Sudanese Childhood Diabetes Association (SCDA), GPED and the training of allied health professionals in Sudan
Visiting Scholar Program between China and USA
Dear GPED community,
I’m sure COVID-19 is on everyone’s minds at the moment as we are trying to keep providing high-quality care for our patients while responding to rapidly evolving circumstances. Patients and their families are understandably worried, may be more so by all the uncertainties rather than the virus itself. Fortunately our pediatric population seems less at risk for severe clinical manifestations and sequelae, and at least for now it seems that some of our most vulnerable patients such as those with diabetes, are not at increased risk either (see JDRF and ISPAD links below). While numbers from many low– and middle-income countries are not (yet?) increasing as rapidly, hearing about the first 2 cases from Haiti yesterday was more worrisome to me than the hundreds of cases in Canada, and the thousands in other high-income countries. COVID-19 mortality is highly likely linked to health care resource availability (www.thelancet.com/journals/langlo/ article/PIIS2214-109X(20)30068-1/fulltext) and clearly these are severely limited in low-resource settings such as Haiti. No matter where we live and practice, let’s keep in mind we are all in this together, let’s support each other and foster solidarity in our communities while adhering to social distancing and handwashing!
Regardless of the corona crisis, GPED is committed to continuing our activities as best as possible. In this letter, we’d like to acknowledge the generous contribution of GPED members that supported GPED’s first fundraising campaign during the 2019 December Holidays—to the tune of 1465 CAD (about 1000 USD). This is a first attempt to generate income for GPED. We acknowledge that many GPED members live in low- and middle-income countries, and, as such, are struggling to make ends meet. We are thankful to those who contributed. The funds have been use in their integrality to provide 6000 tablets of fludrocortisone to countries that need them desperately. With your help, we are committed to identify funding and ensure that medicines are delivered to countries that need them.
Enjoy the read everyone!
-Dr. Julia von Oettingen
New Forum Topic for ISPAD members:
Diabetes management and COVID-19
The ISPAD Communications Committee would like to start a forum discussion for diabetes providers to discuss how the unprecedented global pandemic of COVID - 19 is affecting their patients with diabetes.
Spanish books available on
1. Endocrinología Pediátrica Básica (Spanish) Paperback by Elbi Morla et al.
2. Hiperplasia Suprarrenal Congenita: Una Guia Para Los Padres by C.Y. HSU y S.A Rivkees (Translated from English by Prof R. Calzada)
Telcide Roosler Billy writes about his experience as a visiting fellow in Sudan.
More articles and information available in the full Newsletter: Issue 15
WHO Growth Curves Continued:
The characteristics of the curves include:
· Use of percentiles
· Metric system (kg, cm) and US system (inches and pounds)
· Length/height for age and weight for age are present on the chart
· Weight for age curves are include for boys and girls older than 10 years. These data are presently not available on the charts proposed online by the WHO. Most health professionals agree that BMI is the easiest and most recognized marker to evaluate body mass, in particular during puberty, when weight changes are closely linked to pubertal development. However, many health professionals also like to have the possibility to plot weight for age in all children and adolescents. A Canadian working group has calculated and included weight percentiles on the weight for age chart for children and adolescents older than 10 years. These data are presented as a dotted line, reflecting the importance of primarily using BMI to evaluate body mass, as emphasized by the WHO.
GPED has received many requests to have these charts made widely available under the name of the country where they would be used. Thanks to Public Health Agency of Canada, Canadian group for Pediatric Endocrinology, Dietitians of Canada and with the permission from Dr Mercedes de Onis (WHO, who designed and performed the study for the WHO), this is now possible.
GPED is pleased to make growth charts based on WHO data available in French, English or Spanish with the name of your country. The figures provide examples of the chats in 3 languages and for both boys and girls.
Please contact Dr Jean-Pierre Chanoine, Secretary General, GPED at email@example.com for more information.
Can CAH be effectively treated in children if hydrocortisone tablets are not available?
Your feedback is welcome and will be published in the next newsletter
The management of CAH requires administration of glucocorticoids and, when (sub)clinical salt wasting is present, fludrocortisone. None of the synthetic glucocorticoids that are presently available mimic the physiological rhythm of endogenous cortisol (early morning peak followed by a progressive decrease over 24 hours). Hydrocortisone is traditionally recommended as the first line treatment for glucocorticoid replacement in neonates and children. However, in many countries, hydrocortisone tablets are not available and other synthetic glucocorticoids need to be considered: prednisolone (PRDL), prednisone (PRED), dexamethasone (DEX) (1, 2, 3).
The greatest risk of using these more potent glucocorticoids is overtreatment, decreased height velocity and exogenous Cushing. However, when equivalence doses of 10 (HC) to 1 (PRED and PRDL) or 80-100 (DEX) to 1 (HC) are used, several authors have suggested that careful use of these more potent glucocorticoids can successfully achieve glucocorticoid replacement without side-effects.
GPED@ESPE in Vienna
Friday September 20, 2019, 1400-1600, Room TBD
The Long Winding Road towards Sustainable Access to Affordable Insulin
Join us for an exciting symposium and round table on insulin access during the ESPE meeting in Vienna on Friday September 20, 1400-1600 PM (Room TBD)
Positions available at GPED
Elections during AGM: Sept 20 16-1700)
GPED is accepting nominations for the positions of: Secretary-General, Treasurer and Secretary: send an Email to firstname.lastname@example.org
WHO growth charts now available to GPED members in a new format!!
Get growth charts personalized with the name of your country
Available in English, French and Spanish
Background: Growth monitoring is the single most useful tool for defining health and nutritional status in children at both the individual and population level. In 2006, the World Health Organization (WHO) released new international growth charts depicting the growth of children from birth to age five years, who had been raised in six different countries (Brazil, Ghana, India, Norway, Oman, USA). Because the infants and children included in this study were raised under optimal conditions (including exclusive breastfeeding for the first four to six months of life), these WHO growth charts represent the best description of physiological growth for children from birth to five years of age. As such, they depict the rate of growth that should serve as a goal for all healthy infants and children, regardless of ethnicity, socioeconomic status, and type of feeding. Because of their prescriptive nature, they are growth standards. In 2007, motivated by the global surge in childhood obesity, the WHO also released charts for monitoring the growth of older children and adolescents. These reference curves were constructed using updated and improved data collected by NCHS (National Center for Health Statistics) in 1977 and linked to the WHO Child Growth Standards curves.
Context: Using the original WHO data, Canada has formatted the curves in order to obtain a design that is similar in appearance to growth charts used in many countries in the world and attractive for Canadian health professionals. The set consists in 8 growth charts (4 for boys and 4 for girls): length and weight for age (0-2 years), weight for length and head circumference (0-2 years), height and weight for age (2-19 years), BMI for age (2-19 years).
Welcome to our 2019 GPED fall newsletter!
Just in time before the European Society for Pediatric Endocrinology conference in Vienna, we are getting out this 13th issue, excited to promote the GPED symposium on sustainable access to affordable insulin. Join us for this informative and interactive session, followed by the GPED annual general meeting—see page 1 below for information on available positions.
In other news, our GPED’s secretary general Jean-Pierre Chanoine spent the past few months of his sabbatical working at the World Health Organization headquarters in Geneva during. In this issue, he presents some of his work on three projects relevant to global pediatric endocrinology.
1. Growth curves: The essential “vital sign” in endocrinology, find out how you can create specific growth charts for your country, using original WHO data and formatting by Canadian colleagues (pages 2-3). 2. Congenital adrenal hyperplasia: Join the discussion on whether and how we can adequately treat congenital adrenal hyperplasia in settings where hydrocortisone is unavailable. Do you agree? What is the practice in your country? What pro’s and con’s do you see? (page 4). 3. Congenital hyperinsulinism: There’s an important optimistic update for children, families and health care providers taking care of congenital hyperinsulinism: Diazoxide will be included on the next WHO list of essential medicines! Years of lobbying and a lengthy application to the WHO have finally paid out (page4).
Finally, our colleague Asma Deeb is pointing to current guidelines on diabetes management during Ramadan (page 5).
Enjoy the Read!!
1. Whittle E and Falhammar H. Glucocorticoid regimens in the treatment of congenital adrenal hyperplasia: A systematic review and meta-analysis. J Endocr Soc 2019; 3: 1227-1245
2. Rivkees SA. Dexamethasone therapy of congenital adrenal hyperplasia and the myth of the “Growth Toxic” glucocorticoid. Int J Pediatr 2010, 2010:56968 (10 pages)
3. Rivkees SA and Stephenson K. Low-dose dexamethasone therapy from infancy of virilizing congenital adrenal hyperplasia. Int J Pediatr 2009, 2009:274682 (4 pages)
4. Manchanda A, Laracy M, Savji T, Bogner RH. Stability of an alcohol-free, dye-free hydrocortisone compounded (2 mg/ml) hydrocortisone oral solution
Management of diabetes during Ramadan
Dr Asma Deeb has worked with an international group of ISPAD (International Society for Pediatric and Adolescent Diabetes) diabetes specialists on the development of pediatric and adolescent guidelines for the management of diabetes during Ramadan. In addition, Dr Deeb is a coautor on two related sister publications. The first one summarizes the views on Ramadan fasting and examines the safety of fasting and its impact on diabetes control. The second one is a survey of the perceptions and practices related to the management of diabetes during Ramadan in children and adolescents by the members of the Arab Society for Paediatric Endocrinology and Diabetes (ASPED). Together, these three publications provide a multifaceted understanding of key aspects of the impact of Ramadan on diabetes management in Muslim children and adolescents who practice Ramadan fasting. These articles are also relevant to all pediatric endocrinologists involved in the care of Muslim children and adolescents.
Overall, a wide variation in the management of children and adolescents with diabetes during Ramadan was observed in ASPED countries emphasizing the need for guidelines. The guidelines start with an explanation of the history, importance and rationale for Ramadan in the life of a Muslim. It stresses that although observing the Ramadan fast is a key aspect of religious life, patients with chronic conditions such as diabetes are exempt from this obligation.
Deeb A, Elbarbary N, Smart C, Beshyah SA, Habeb A, Kalra S, Al Alwan I, Babiker A, Al Amoudi R, Pulungan AB, Humayun K, Issa U, Yazid M, Sanhay R, Akanov Z, Krogvold L, de Beaufort C. ISPAD Clinical Practice Consensus Guidelines: Fasting Ramadan by young people with Diabetes. Pediatr Diabetes 2019 (in press)
Beshyah SA, Habeb AM, Deeb A, Elbarbary NS. Ramadan fasting and diabetes in adolescents and children: A narrative review. Ibnosina J Med Biomed Sci 2019 (in press)
Elbarbary N, Deeb A, Habeb A, Beshyah SA. Management of diabetes during Ramadan fasting in children and adolescents: A survey of physicians’ perceptions and practices in the Arab Society for Paediatric Endocrinology and Diabetes (ASPED) Countries. Diabetes Res Clin Pract 2019; 150: 274-281
Deeb A, Al Qahtani N, Akle M, Singh H, Assadi R, Attia S, Al Suwaidi H, Hussain T, Naglekerke N. Attitude, complications, ability of fasting and glycemic control in fasting Ramadan by children and adolescents with type 1 diabetes mellitus. Diabetes Res Clin Pract 2017; 126: 10-15
For information and reprints, please contact Dr Asma Deeb, Paediatric Endocrinology Department, Mafraq Hospital, Abu Dhabi & Gulf University, Ajman, UAE. Email: Adeeb@seha.ae
Happy New Year! While many of you may start to settle into 2019, the first GPED newsletter of the year is looking back at 2018, providing you with a broad range of global pediatric endocrinology highlights. We have summarized 2018’s global pediatric endocrinology related publications in this year’s European Society for Pediatric Endocrinology Yearbook, are reporting on Chile’s 2018 global pediatric endocrinology education events, are showcasing important advocacy efforts on congenital hyperinsulinism and global access to insulin, and highlighting new guidelines for newborn screening in India. In other news, in an effort to broaden the perspective on global pediatric endocrine issues, we are excited to announce the expansion of the GPED newsletter editorial team to 5 (!) additional colleagues from across the globe, spanning from Latin America, the Middle East, China and India all the way to Africa. Contributions from you, our members & readers remain more than welcome—send us your notice of events, announcements, your Op-Ed or commentaries to email@example.com.
Newborn Screening for Congenital Hypothyroidism in India: Let’s Start!
An estimated 24 million babies are born every year in India. So far, systematic newborn screening for congenital hypothyroidism (NBS CH) has not been routinely available on a national level but the Indian Society for Pediatric and Adolescent Endocrinology (ISPAE) wants this to change. In 2018, ISPAE published two landmark papers that define the process of NBS CH in India.
#Insulin4All - the global crisis on insulin access
In 1921, almost 100 years ago, the discovery of insulin by Banting, McLeod, Best and Phillips lifted the death sentence off of type 1 diabetes (T1D). It became a treatable chronic condition for those with access to insulin. Aware of the impact, the scientists gave away any proprietary rights so that insulin could be made available to all who needed it. Fast forward to 2018, the most common cause of death for children with T1D remains lack of access to insulin.
ESPE Yearbook 2018: Global Health Highlights
Since 2016, the traditional European Society for Pediatric Endocrinology Yearbook of Pediatric Endocrinology has included a chapter on Global Health for the Pediatric Endocrinologist. The 2018 edition is no different! For the first time, the yearbook is exclusively available online at http://www.espeyearbook.org, while the global health chapter can be found at http://www.espeyearbook.org/ey/0015/ey0015.13.htm.