Today, the world is faced with Coronavirus 2019 (COVID-19) outbreak. This pandemic has compelled us to stay at home to break the chain of infectivity. The Coronavirus (CV) is here to stay for a long time as we wait for a specific treatment and/or vaccine. Hence, it’s time to educate ourselves when to recognize the red flag signs in children and adolescents and not hesitate to visit the emergency department of the hospital. As regular doctor visits will need social distancing as the new normal for the foreseeable future, it will be prudent to restrict in-person hospital visits for the safety of patients as well as healthcare workers by consulting through video consultation and teleconsultation (telemedicine).
Endocrine conditions are chronic hormonal conditions; hence attention towards such children with endocrine diseases requires collaboration with Pediatric Endocrinologists, Pediatricians, and those in Emergency units.
In children, it is encouraging to know that CV illness generally has a milder course. At present, there are no reliable data suggesting that children and adolescents with well-managed endocrine conditions (including Type 1 Diabetes Mellitus) are at an increased risk of getting infected or becoming severely ill with CV. However, a delay in contacting a doctor or identifying the signs of sickness can put these children at risk of exaggerating their underlying endocrine illness. Poorly controlled diabetes mellitus can weaken immunity and the risk of getting infected by the virus. There are some indications that otherwise healthy, but severely obese children are at an increased risk of greater lung involvement in a COVID-19 infection. Hence, parents and caregivers of children with endocrine conditions are advised strict application of safe and preventive measures to prevent COVID-19 infection.
Here is some advice in regards to regular care, sick day management, and identifying red flag signs in children and adolescents with endocrine diseases:
- Please stay in touch with your Pediatric Endocrinologists and Pediatricians
- Contact details: SRCC Children’s Hospital has a working 24/7 Emergency department
- Pediatric and Speciality OPDs: To maintain social distance and safety –
- Restricted in-person with prior appointments
- Type 1 Diabetes Mellitus:
There are anecdotal reports that children with diabetes have not shown a different disease pattern compared to their peers. Also, as usual, it is important to maintain good glycemic control and regular contact with the Diabetes care team via phone calls, video calls, and emails as teleconsultation. Children with diabetes who are infected with COVID-19 may experience a deterioration of glycemic control during the illness, like in any other infectious episodes. It is important to implement Sick day rules to overcome potential diabetes decompensation (Diabetes Ketoacidosis and Hypoglycemia).
During illness: General sick-day diabetes management principles –
- More frequent blood glucose and ketone (blood or urine) monitoring. Aim for a blood glucose level between 70-180 mg/dL and blood ketones below 0.6 mmol/L (negative/trace in urine) when the child is ill.
- NEVER STOP INSULIN.
- Monitor and maintain hydration with adequate salt and water balance.
- Treat underlying illnesses and symptoms (fever, cough, cold, vomiting, and diarrhea).
- Make sure Insulin is not frozen or kept in direct sunlight and heat as it will not work. Change vial/pen/cartridge, if in doubt.
URGENT: Emergency care must be obtained when:
- Fever or vomiting persists and/or weight loss continues.
- Blood ketones remain elevated >1.5 mmol/L or urine ketones remain large despite extra insulin and hydration.
- The child or adolescent is exhausted, confused, has difficulty in breathing or severe abdominal pain.
- Adrenal insufficiency:
So far, there is no reported data on COVID-19 infection outcomes in adrenal insufficient subjects due to Congenital Adrenal Hyperplasia (CAH), Panhypopituitarism (Pituitary Failure), Addison’s disease, after long-term use of steroid medication, or any other cause. In CV infection, a stress dose of the replacement treatment (Hisone/Hydrocortisone) as indicated for the Sick day management, should be initiated with the appearance of minor symptoms. Contact your Pediatric Endocrinologist or emergency department of the hospital.
- Hypoglycemia or low blood glucose in Type 1 Diabetes Mellitus, Congenital Hyperinsuilinemic Hypoglycemia (CHI or PHHI), Adrenal Insufficiency/Congenital Adrenal Hyperplasia (CAH):
Be aware of the symptoms of low blood sugar –
Excessive sweating, shakiness, trembling, blurred vision, hunger, irritability, nightmares, weakness, dizziness, seizures, loss of consciousness.
In Type 1 Diabetes Mellitus, it’s important to check on blood sugar when a child is sick or after an unexpected excess activity or decreased intake.
In CHI/PHHI, it’s important to feed the child frequently with complex carbohydrate-containing meals especially during illness, along with frequent blood sugar checks.
It’s important to stay healthy even during this unprecedented time. Healthy weight maintenance is important to prevent complications during CV infection and also in the future.
COVID-19 Pandemic lockdown has given us an opportunity:
- To eat healthy, home-cooked freshly prepared food as a sit-down, family meal.
- No time constraints on physical activity and exercise. Even though open grounds were an issue earlier and we had adapted to utilize our home ground for a variety of aerobic exercises and yoga. Today, this can be extended to include the entire family as a team health goal.
- Due to online homeschooling, screen view has increased. This can be limited to just schooling screen exposure and other leisure screen activities can be restricted. To this, an added advantage is to provide children with an opportunity to follow their creative hobbies or develop new ones.
- Sleep can be better regularized to 9-11 hours every day.
- Children can be taught simple household chores, which can keep them preoccupied and distracted from screens. Also, reading and role-plays can be encouraged in them.
- Other endocrine conditions during CV illness:
In the case of CV illness in children with various other endocrine conditions, we expect the same course of the illness as their peers and recommend following the usual management advice for sick children.
Children on treatment for hypertension, dyslipidemia, Type 2 Diabetes Mellitus, or Insulin resistance and polycystic ovarian syndrome should continue their treatment as usual and stay in touch with their doctor through teleconsultation. If they develop CV like symptoms, they need to inform their Pediatricians and Pediatric Endocrinologists for further course of action.
All children on thyroid medications should continue their medications as usual and can postpone routine doctor visits but avail of video/teleconsultation. In case of any illness or suspected COVID-19 symptoms should contact their Pediatrician and Pediatric Endocrinologist, especially for children on treatment for hyperthyroidism or Graves disease.
Pubertal and Growth disorders:
All children on puberty medication (for early or delayed puberty) and growth hormone therapy should continue their medications, as usual, can postpone routine doctor visits but avail of video/teleconsultation. If you run out of medicines, you can purchase more, and continue the same dose as before, till you consult the doctor again.
- Insulin, hydrocortisone, and other medications supply during the global outbreak: Maintain the usual amount of back-up insulin/hydrocortisone/other medications for at least a week in advance. We do not recommend stocking up larger quantities, since they can be made available by our hospital or nearby chemist/pharmacy. Also, this helps to prevent disruption of supply or cold chain.
- There has been a rapid increase in teleconsultation as a way to continue to care for children and adolescents with endocrine conditions throughout the world. Communication with healthcare teams is vitally important. This can avoid visits to clinics or hospitals and provide needed advice and reduce the risk for COVID-19 transmission.
- Please bear in mind that our current knowledge on COVID-19 is limited by the lack/limitation of data, and further information and guidance will be provided as new data becomes available.
- ISPAD Summary of Recommendations regarding COVID-19 in children with diabetes.
- ESPE – COVID-19 Information for children and adolescents living with endocrine conditions including Type 1 Diabetes Mellitus.
- Need for Hospital Visit during COVID-19 Pandemic – A brief guide to the parents of children with hormone problems. Dr. Sirisha Kusuma B.
- ISPAE Instructions for children with diabetes during COVID Pandemic.
- Research Society for the Study of Diabetes in India (RSSDI) advice for people living with diabetes and their families for Coronavirus (COVID-19).