Diabetes & Endocrinology

Mother helping son check blood sugar levels

Supporting parents and children through diabetes diagnosis

Mother helping son check blood sugar levels

Behavioral intervention can improve parents’ mood following their child’s diabetes diagnosis.

Results from a new study show that behavioral intervention improved parents’ mood following young children’s Type 1 diabetes diagnosis.

The study evaluated First STEPS, a stepped-care behavioral intervention designed to support parents’ psychosocial functioning and promote children’s glycemic outcomes. Results indicated likely benefits of parent coach support, supplemented by intervention intensifications, including behavioral intervention and diabetes education.

“We found that parent coaches, or parents of slightly older children with Type 1 diabetes who were trained in offering peer support, were helpful in reducing parent depressive symptoms up to one year and a half following diagnosis for parents in the stepped care group,” says Randi Streisand, Ph.D., C.D.C.E.S., Psychology and Behavioral Health division chief at Children’s National Hospital and senior author of the study. “The second study target, child glycemic control, was not significantly different between the two groups.”

What’s been the hold-up in the field?

There are unique challenges facing families of young children with Type 1 diabetes. However, typical care and management guidelines are not specific to young children.

“Many parents of children diagnosed with diabetes experience distress and symptoms of depression, yet parents are not routinely screened during clinic visits,” Dr. Streisand says. “Further, there are many barriers to mental health support.”

Moving the field forward

Findings also highlighted the potential for training lay people who have a shared lived experience (parent coaches), which could be incorporated into clinical programs.

Most behavioral interventions use behavioral health experts. The study’s experts demonstrated significant outcomes in parent mood by using parent coaches.

“The goal would be to incorporate parent coach programs into the clinic setting, to either offer the support to all families at the time of diagnosis or to screen families and provide support to those in need,” Dr. Streisand adds.

The authors affirm this model has high potential for patient engagement. Additionally, results showed that incorporating targeted behavioral support for intensive diabetes treatment may maximize intervention impact.

Other Children’s National authors include: Carrie Tully, Ph.D.; Christine Wang, Ph.D.; Lauren Clary, Ph.D.; Fran Cogen, M.D.; John Barber and Celia Henderson.

You can read the full study First STEPS: Primary Outcomes of a Randomized, Stepped-Care Behavioral Clinical Trial for Parents of Young Children With New-Onset Type 1 Diabetes in Diabetes Care.

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Children’s National named to U.S. News & World Report’s Best Children’s Hospitals Honor Roll

US News BadgesChildren’s National Hospital in Washington, D.C., was ranked No. 5 nationally in the U.S. News & World Report 2022-23 Best Children’s Hospitals annual rankings. This marks the sixth straight year Children’s National has made the list, which ranks the top 10 children’s hospitals nationwide. In addition, its neonatology program, which provides newborn intensive care, ranked No.1 among all children’s hospitals for the sixth year in a row.

For the twelfth straight year, Children’s National also ranked in all 10 specialty services, with seven specialties ranked in the top 10.

“In any year, it would take an incredible team to earn a number 5 in the nation ranking. This year, our team performed at the very highest levels, all while facing incredible challenges, including the ongoing pandemic, national workforce shortages and enormous stress,” said Kurt Newman, M.D., president and chief executive officer of Children’s National. “I could not be prouder of every member of our organization who maintained a commitment to our mission. Through their resilience, Children’s National continued to provide outstanding care families.”

“Choosing the right hospital for a sick child is a critical decision for many parents,” said Ben Harder, chief of health analysis and managing editor at U.S. News. “The Best Children’s Hospitals rankings spotlight hospitals that excel in specialized care.”

The annual rankings are the most comprehensive source of quality-related information on U.S. pediatric hospitals and recognizes the nation’s top 50 pediatric hospitals based on a scoring system developed by U.S. News.

The bulk of the score for each specialty service is based on quality and outcomes data. The process includes a survey of relevant specialists across the country, who are asked to list hospitals they believe provide the best care for patients with the most complex conditions.

The seven Children’s National specialty services that U.S. News ranked in the top 10 nationally are:

The other three specialties ranked among the top 50 were cardiology and heart surgery, gastroenterology and gastro-intestinal surgery, and urology.

DNA

New research on genetic evaluation of short stature, discussed by Andrew Dauber, M.D., M.M.Sc.

DNA

In this study, the authors at Shanghai Children’s Medical Center utilized next-generation sequencing (NGS) to analyze the data of patients with short stature to better understand the etiologies of short stature.

Andrew Dauber, M.D., M.M.Sc., division chief of Endocrinology at Children’s National Hospital, shared expert commentary on a recent study published in The Journal of Clinical Endocrinology & Metabolism that explores associated risk factors of short stature as identified by exome sequencing in children.

In this study, the authors at Shanghai Children’s Medical Center utilized next-generation sequencing (NGS) to analyze the data of patients with short stature to better understand the etiologies of short stature.

The big picture

“This was a large-scale study looking at 814 children with short stature and at least one more clinical feature suggestive of a genetic condition who underwent comprehensive genetic testing at Shanghai Children’s Medical Center,” explains Dr. Dauber. In this study, the authors identified a potential genetic etiology in 361 of the patients, which is 44% of the cohort.

“It is important to note that the yield of genetic testing was highly variable depending on the clinical presentation of the child,” said Dr. Dauber. “For example, patients with associated congenital anomalies or a suspected skeletal dysplasia had a diagnostic yield of 56% and 65% respectively, while patients with isolated severe short stature (defined as a height below -3 SDS) only had a yield of 11%.”

Dr. Dauber noted that the overall high yield is reflective of the types of patients who are referred to this specialty center, and the expected yield in a more general pediatric setting is likely much lower.

The patient benefit

“This study helps shed light on the prevalence of those patients in a large cohort of children presenting for evaluation of short stature,” shared Dr. Dauber. “I am hopeful that targeted treatments will improve growth in these children.”

While this study provides new insights into the underlying causes behind short stature in patients with differing phenotypes, the authors indicate that additional large-scale studies on short stature exome sequencing are warranted.

Moving the field forward

Dr. Dauber also pointed to the fact that the authors note a large number of the patients in this study had undiagnosed Rasopathies, such as Noonan syndrome. “There were also 31 patients with FGFR3 mutations, 6 patients found with ACAN (Aggrecan) mutations and 2 with NPR2 mutations,” said Dr. Dauber.

“At Children’s National, we are currently conducting a clinical trial of vosoritide, a novel growth promoting agent which targets the growth plate in children with selected genetic conditions including Noonan syndrome and patients with mutations in FGFR3, ACAN, and NPR2,” included Dr. Dauber. Preliminary results from this clinical trial were recently presented by Dr. Dauber at the Pediatric Endocrine Society annual meeting.

You can read the full study Clinical Profiles and Genetic Spectra of 814 Chinese Children With Short Stature in The Journal of Clinical Endocrinology & Metabolism.

doctor measuring girl's height

Vosoritide shows promise for children with certain genetic growth disorders

doctor measuring girl's height

This is the first clinical trial in the world testing vosoritide in children with certain genetic causes of short stature, including hypochondroplasia, Noonan syndrome, NPR2 mutations and Aggrecan mutations.

Andrew Dauber, M.D., M.M.Sc., endocrinologist at Children’s National Hospital, presented preliminary results from a phase II clinical trial of a new drug, vosoritide, used to treat children with certain growth disorders, at the Pediatric Endocrine Society annual meeting held virtually on May 1.

Vosoritide is a C-type natriuretic peptide analog that binds its receptor on chondrocytes, leading to increased chondrocyte proliferation and differentiation via its inhibition of the ERK1/2-MAPK pathway.

This is the first clinical trial in the world testing vosoritide in children with certain genetic causes of short stature, including hypochondroplasia, Noonan syndrome, NPR2 mutations and Aggrecan mutations.

To date, 34 participants have enrolled in the trial with a median baseline height of -3.2 SD (interquartile range (IQR) -3.7, -2.6). 18 subjects have initiated on vosoritide and twelve have completed six months of therapy. The authors note that the mean increase in annualized growth velocity (AGV) was 1.8 cm/yr for subjects with hypochondroplasia and 6.1 cm/yr for subjects with Noonan syndrome or NPR2 mutations. The two subjects with NPR2 mutations had increased AGVs of 4.4 and 9.2 cm/yr, while the two subjects with Noonan syndrome had increased in AGVs of 7.5 and 3.3 cm/yr. One of the Noonan syndrome subjects was previously treated with growth hormone (GH) for 2 years and AGV was 6.7 cm/yr while on GH, 4.1 cm/yr during the trial 6-month observation period and 11.6 cm/year during the first six months of vosoritide treatment.

To the researchers, the safety profile is quite reassuring. So far, the preliminary results showed increased growth in all the genetic subgroups with the patients with hypochondroplasia demonstrating a response similar to that seen previously in patients with achondroplasia. While the results are very promising for patients with Noonan syndrome and NPR2 mutations, the clinical trial must be completed before drawing further conclusions. The experts also plan to submit the study to a peer-reviewed journal in the future to validate the findings.

The big picture

This is the first medication that directly targets the pathway in chondrocytes (cells in the growth plate that make the bones grow longer) affected by these specific mutations. This means that the novel approach may give patients additional therapeutic options outside of growth hormone.

Why we’re excited

“These are the first patients in the world to ever receive this medication for their conditions,” said Dr. Dauber. “The results are very promising and may change the way we practice medicine. Patients have come from all over the world to participate in the study.”

Children’s National leads the way

This clinical trial funded by BioMarin is the first of its kind to treat children with genetic short stature who do not have achondroplasia. Children’s National is the only site in the world offering this therapy for patients with these conditions.

Find out more about the trial here.

Shideh Majidi

Shideh Majidi, M.D., M.S.C.S, brings focus on psychosocial research in diabetes patients to Children’s National

Shideh Majidi

Dr. Majidi specializes in Type 1 diabetes and has been involved in innovative research studying behavioral and psychosocial aspects of health care such as anxiety, depression and suicide and improving high-risk patient management for children with the disease.

Children’s National Hospital welcomes Shideh Majidi, M.D., M.S.C.S., as the new associate director of the Childhood and Adolescent Diabetes Program. Dr. Majidi specializes in Type 1 diabetes and has been involved in innovative research studying behavioral and psychosocial aspects of health care such as anxiety, depression and suicide and improving high-risk patient management for children with the disease.

Dr. Majidi comes to Children’s National from the Barbara Davis Center for Diabetes where, in addition to providing clinical care in the Pediatric Diabetes Division, she was the assistant professor of pediatric endocrinology, head of the depression screening and high-risk task force committees, developer and director of an online class for children managing their Type 1 diabetes and a member of several committees focusing on program evaluation and residency and fellowship recruitment.

When Andrew Dauber, M.D., M.M.Sc., took over the role of division chief of Endocrinology, his goal was to create a clinical endocrinology research program to provide cutting-edge treatment for families. Dr. Dauber is excited to have Dr. Majidi bring her expertise to the team to further this goal. “Dr. Majidi has played a key role in national cooperative research on quality improvement in pediatric diabetes care and is now leading an international collaborative focused on preventing suicide in individuals with Type 1 diabetes,” says Dr. Dauber. “Her compassion, intellect and commitment to improving care for all children with diabetes is an inspiration to us all.”

Dr. Majidi will continue to serve in her roles as site co-lead for Type 1 Diabetes Exchange Quality Improvement Collaborative, where she recently led a 2021 study exploring inequities in access to and outcomes of health care for those with Type 1 diabetes, and  co-chair for RESCUE, which aims to reduce suicide rates among individuals with diabetes.

She is dedicated to meeting patients and families where they are to help provide the best care. “We may think we see a lack of effort in diabetes care from patients and families, but we need to reframe our mindset and dig deeper to determine what barriers are in the way of diabetes management– behavioral, psychosocial or otherwise,” says Dr. Majidi. “When we do this, we can then work on how to help families manage and overcome the barriers that affect their diabetes care.”

aggrecan protein

Two new papers advance aggrecan deficiency research

aggrecan protein

Aggrecan (ACAN) is a large protein found in joint cartilage and growth plates.

Andrew Dauber, M.D., M.M.Sc., division chief of Endocrinology at Children’s National Hospital, and colleagues recently published two papers that describe the phenotypic spectrum of aggrecan deficiency and look at treating the condition with human growth hormone.

Aggrecan (ACAN) is a large protein found in joint cartilage and growth plates. It allows joints to move smoothly and without pain. Aggrecan deficiency — due to heterozygous mutations in the ACAN gene — causes dominantly inherited short stature and, in many patients, early-onset osteoarthritis and degenerative disc disease.

Clinical phenotype of patients with aggrecan deficiency

In 2017, Dr. Dauber led an international consortium of researchers that published a manuscript describing the phenotypic spectrum of 103 individuals – 70 adults and 33 children, including 57 females and 46 males – from 20 families with ACAN mutations. In the study, Dr. Dauber and his colleagues established that short stature and accelerated bone age is common among people with ACAN mutations.

In a new study published in the American Journal of Medical Genetics Part A, Dr. Dauber and colleagues further characterize the phenotypic spectrum of aggrecan deficiency, with an emphasis on musculoskeletal health.

Twenty-two individuals from nine families were enrolled in the study. Recorded histories and examinations focused on joint health, gait analysis, joint specific patient reported outcomes and imaging.

“We performed a detailed analysis of the musculoskeletal manifestations in patients with mutations in the aggrecan gene,” says Dr. Dauber. “We found that patients with mutations in this gene had significant short stature which worsened with age. There was a high prevalence of joint complaints and arthritis in adults, and we were able to detect pre-symptomatic joint damage in children using knee MRIs.”

Treating short stature in aggrecan-deficient patients with human growth hormone

Until now, it was unknown how to treat children with aggrecan deficiency. “Providing growth hormone therapy to children with ACAN gene mutations is relatively new in the field of pediatric endocrinology,” explains Dr. Dauber. “Previously, the assumption was that this was just short stature.”

In a new study, published in The Journal of Clinical Endocrinology and Metabolism, Dr. Dauber and colleagues reported the results of a trial that evaluated the efficacy and safety of recombinant human growth hormone (rhGH) therapy on linear growth in children with ACAN deficiency.

“This is the first prospective trial of growth hormone therapy in patients with mutations in the aggrecan gene,” says Dr. Dauber. “Mutations in the gene are the cause for short stature in approximately 2%  of individuals with idiopathic short stature.”

The open-label, single-arm, prospective study enrolled ten treatment-naïve patients with a confirmed heterozygous mutation in ACAN. Participants were treated with rhGH (50 µg/kg/day) over 1 year. Main outcomes measured were height velocity and change in height standard deviation score.

The authors found that growth hormone led to short term improvements in growth rate over the course of the year. The treated patients had their growth rate increase from 5.2 centimeters per year to 8.3 centimeters per year while on therapy.

In 2019, the researchers received the 2019 Human Growth Award at the Pediatric Endocrine Society’s Annual Meeting for an abstract related to this work, entitled “Clinical Characterization and Trial of Growth Hormone in Patients with Aggrecan Deficiency: 6 Month Data.”

Med Games Logo

Continuing medical education through online games

Med Games LogoAndrew Dauber, M.D., MMSc., chief of Endocrinology at Children’s National Hospital, participated as the faculty chair of a Med Games CME educational online activity, to provide continuing medical education for physicians. This game-based activity is intended to meet the educational needs of endocrinologists, endocrine fellows, primary care physicians, physician assistants, nurse practitioners and health care professionals who diagnose and manage children with growth hormone deficiency (CGHD). This CME educational program is provided by Med Learning Group and supported by an educational grant from Novo Nordisk Inc.

Learn more about the program and test your knowledge: ‘Accurate Diagnosis and Effective Management of Children with Growth Hormone Deficiency: What Can You Do to Improve Patient Outcomes in Your Clinical Practice?’

kale at the food pharmacy

Capital Area Food Bank and Children’s National launch food pharmacy program

kale at the food pharmacy

The goal of the food pharmacy program is to improve patient health by creating easy access to foods that help with the management of diabetes, and to reduce barriers to routine attendance at clinic appointments by co-locating food assistance with medical care.

Capital Area Food Bank and Children’s National Hospital launched a pilot program, hosted by the Diabetes and Endocrinology teams at Children’s National, that will enable children with prediabetes and diabetes who are experiencing food insecurity to leave their visits with nutritious groceries from an on-site “food pharmacy.”

“We know that good food and good health are deeply interconnected, especially for young people,” said Radha Muthiah, president and CEO of the Capital Area Food Bank. “For children whose families may not always have the resources to get a nutritious meal on the table, all kinds of health challenges can emerge, including diabetes. We’re proud to be partnering with Children’s National on an initiative that will enable brighter futures for kids by making healthy groceries available right at the point of care.”

The goal of the food pharmacy program is to improve patient health by creating easy access to foods that help with the management of diabetes, and to reduce barriers to routine attendance at clinic appointments by co-locating food assistance with medical care. Children diagnosed with prediabetes or diabetes (Types 1 and 2) who also screen positive for food insecurity are given a prescription for medically-tailored groceries, which can be filled immediately on site. The supply includes both produce and shelf-stable items. Families are also provided with information about where to find additional help obtaining food, along with nutrition education materials.”

Rates of type 2 diabetes and prediabetes in children have been rapidly increasing in the past years, partly a consequence of the epidemic of childhood obesity. These conditions disproportionally impact children of African and Hispanic descent and those coming from low-income families, according to Elizabeth Estrada, M.D., director of the Type 2 Diabetes Program at Children’s National Hospital.

“Healthy eating is crucial in the treatment and prevention of these conditions, but many of our families lack access to nutritious food,” said Dr. Estrada. “The partnership with the Capital Area Food Bank to establish a food pharmacy within the diabetes clinic allows us to not only help our patients and families with recommendations for healthy eating, but also provides them with the foods they need to prepare nutritious meals.”

Through the initiative, the Capital Area Food Bank and Children’s National aim to reach up to 120 unique families per month, providing each household with 35 pounds of food per visit over the course of a year.

insulin pump

Diabetes technology use in the cystic fibrosis community

insulin pump

Although diabetes technologies are associated with improvements in glycemic control and health-related quality of life among people with type 1 diabetes (T1D), the use and perceptions of continuous glucose monitors (CGM) and insulin pumps within the cystic fibrosis (CF) community have not been well documented.

In a recent study published in Diabetes Technology & Therapeutics, Brynn Marks, M.D., MS-HPEd, and co-authors, found that compared to T1D, rates of sustained diabetes technology use in the cystic fibrosis-related diabetes (CFRD) community are low, despite perceived benefits. The authors conclude that better insurance coverage to mitigate cost, better patient education and confirmation that these technologies improve health and patient-reported outcomes may increase uptake.

Read the full article in Diabetes Technology & Therapeutics.

doctor taking blood sample from child

Study shows increase in diabetes cases during COVID-19 pandemic

doctor taking blood sample from child

A retrospective study found pediatric Type 1 diabetes cases rose 15.2% and Type 2 diabetes cases increased by 182% during the first year of the COVID-19 pandemic compared to the prior two years— affecting non-Hispanic Black youth the most.

While the effects of COVID-19 on diabetes-related outcomes are extensively studied in adults, data about the incidence and severity of presentation of pediatric new-onset Type 1 diabetes (T1D) and Type 2 diabetes (T2D) is limited. A new retrospective study of 737 youth diagnosed with diabetes at Children’s National Hospital between March 11, 2018 and March 10, 2021 found pediatric T1D cases rose 15.2% and T2D cases increased by 182% during the first year of the COVID-19 pandemic compared to the prior two years — affecting non-Hispanic Black youth the most.

The study, published in Hormone Research in Paediatrics, compared T1D and T2D cases during the first 12 months of the pandemic, between March 11, 2020 and March 10, 2021, to the same time in the previous two years. This increase in cases was accompanied by a nearly six-fold rise in diabetic ketoacidosis (DKA) and a 9.2% incidence of hyperosmolar DKA during the pandemic as compared to no cases in the two years prior.

“A better understanding of the impact of the COVID-19 pandemic is crucial for raising public awareness, shaping policy and guiding appropriate health screenings,” said Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National and lead author of the study.

Children’s National provides clinical care to approximately 1,800 youth with T1D and 600 youth with T2D annually. In the two years before the pandemic, cases of T2D accounted for 25.1% of all newly diagnosed diabetes at Children’s National compared to 43.7% during the pandemic. Before the pandemic, females accounted for 59.6% of youth with new-onset T2D but 58.9% of new-onset T2D cases were among males during the pandemic.

The researchers noted that the rise in cases of T2D and severity of presentation of both T1D and T2D during the pandemic disproportionately impacted non-Hispanic Black youth (NHB). NHB youth accounted for 58% of cases of T2D pre-pandemic, which further increased to 77% during the pandemic. The findings also showed that cases of DKA among NHB youth newly diagnosed with T1D increased during the pandemic compared to the two years before (62.7% vs. 45.8%, p=0.02).  Before the pandemic, there was no significant difference in A1c at T1D diagnosis between racial and ethnic groups. However, during the pandemic, hemoglobin A1c levels were higher among NHB youth.

“Future studies are needed to understand the root cause of the disproportionate impact of the COVID-19 pandemic on non-Hispanic Black youth with newly diagnosed diabetes,” said Dr. Marks. “These outcomes during the pandemic will likely worsen pre-existing health care disparities among youth with diabetes.  In understanding the indirect effects of our response to the pandemic, we can better inform future emergency responses and develop strategies to improve outcomes for all youth living with diabetes.”

Blood sample tube for anti-Müllerian hormone

A look at the clinical utility of anti-Mullerian hormone

Blood sample tube for anti-Müllerian hormone

Anti-Mullerian hormone (AMH), also known as Mullerian inhibiting substance (MIS), is a hormone produced exclusively in the gonads. It was originally described in the context of sexual differentiation in the male fetus but has gained prominence now as a marker of ovarian reserve and fertility in females.

In a mini-review published in The Journal of Clinical Endocrinology and Metabolism, Roopa Kanakatti Shankar, M.D., pediatric endocrinologist at Children’s National Hospital and an associate professor of pediatrics at the George Washington University School of Medicine and Health Sciences, and co-authors offer an updated synopsis on AMH and its clinical utility in pediatric patients.

The authors performed a systematic search for studies related to the physiology of AMH, normative data and clinical role in pediatrics. After reviewing 70 clinical studies and systematic reviews, they conclude that, “AMH has widespread clinical diagnostic utility in pediatrics but interpretation is often challenging and should be undertaken in the context of not only age and sex but also developmental and pubertal stage of the child.”

Other authors from Children’s National Hospital include Andrew Dauber, M.D., MMSc, Tazim Dowlut-Mcelroy, M.D., and Veronica Gomez-Lobo, M.D.

Read the full review in The Journal of Clinical Endocrinology and Metabolism.

blood glucose monitoring system

Patterns of continuous glucose monitoring use in young children after T1D diagnosis

blood glucose monitoring system

The findings suggest that, when clinically appropriate, continuous glucose monitoring initiation near or at the time of diagnosis benefits glycemic outcomes in young children when followed by sustained use.

Continuous glucose monitoring (CGM) is a blood glucose monitoring device worn on the body that is linked to positive glycemic outcomes in people with Type 1 diabetes (T1D). However, very little research has examined CGM use and glycemic outcomes in young children, particularly those newly diagnosed with T1D.

A new Diabetes Technology and Therapeutics study led by Randi Streisand, Ph.D., C.D.C.E.S., Chief of Psychology and Behavioral Health at Children’s National Hospital, and others identified four meaningful trajectories of CGM use among young children across 18-months post-T1D diagnosis: those who “always” used CGM; those who got on CGM later but stayed on it (“late/stable”); those who used CGM inconsistently; and those who “never” used CGM. The investigators conducted a study of 157 parents of young children (1-6 years) newly diagnosed with T1D who enrolled in a behavioral intervention.

Importantly, the authors found that those with private insurance were more likely than those with only public insurance to be in the “always” and “late/stable” groups (as opposed to the “never” group). Those in the “always” and “late/stable” groups also had better glycemic outcomes than those in the “never group” at 18-months post-T1D diagnosis.

“This research highlights that insurance type can be a barrier to accessing CGM,” Dr. Streisand noted. “Further, this is one of the first studies, among newly diagnosed young children, to show that CGM initiation at diagnosis or near diagnosis followed by sustained use is associated with better glycemic outcomes compared to never initiating CGM, supporting findings from other studies conducted with older youth.”

The findings inform clinical care with patients as it suggests that, when clinically appropriate, CGM initiation near or at the time of diagnosis benefits glycemic outcomes in young children when followed by sustained use. This is the only study to examine patterns of CGM use among 1-6-year-old children newly diagnosed with T1D over the first 18-months post-diagnosis.

“It was exciting to find differences in glycemic outcomes based on CGM initiation and use in this unique population,” Dr. Streisand said. However, the authors concluded that, given the health benefits of CGM, further exploration of barriers to CGM access and use among some families is needed.

In addition to Dr. Streisand, other Children’s National co-authors include Brynn Marks, M.D., M.S. HPEd.; Carrie Tully, Ph.D.;  Maureen Monaghan, Ph.D., C.D.E. , and Christine Wang, Ph.D.

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For fifth year in a row, Children’s National Hospital nationally ranked a top 10 children’s hospital

US News badges

Children’s National Hospital in Washington, D.C., was ranked in the top 10 nationally in the U.S. News & World Report 2021-22 Best Children’s Hospitals annual rankings. This marks the fifth straight year Children’s National has made the Honor Roll list, which ranks the top 10 children’s hospitals nationwide. In addition, its neonatology program, which provides newborn intensive care, ranked No.1 among all children’s hospitals for the fifth year in a row.

For the eleventh straight year, Children’s National also ranked in all 10 specialty services, with seven specialties ranked in the top 10.

“It is always spectacular to be named one of the nation’s best children’s hospitals, but this year more than ever,” says Kurt Newman, M.D., president and CEO of Children’s National. “Every member of our organization helped us achieve this level of excellence, and they did it while sacrificing so much in order to help our country respond to and recover from the COVID-19 pandemic.”

“When choosing a hospital for a sick child, many parents want specialized expertise, convenience and caring medical professionals,” said Ben Harder, chief of health analysis and managing editor at U.S. News. “The Best Children’s Hospitals rankings have always highlighted hospitals that excel in specialized care. As the pandemic continues to affect travel, finding high-quality care close to home has never been more important.”

The annual rankings are the most comprehensive source of quality-related information on U.S. pediatric hospitals. The rankings recognize the nation’s top 50 pediatric hospitals based on a scoring system developed by U.S. News. The top 10 scorers are awarded a distinction called the Honor Roll.

The bulk of the score for each specialty service is based on quality and outcomes data. The process includes a survey of relevant specialists across the country, who are asked to list hospitals they believe provide the best care for patients with the most complex conditions.

Below are links to the seven Children’s National specialty services that U.S. News ranked in the top 10 nationally:

The other three specialties ranked among the top 50 were cardiology and heart surgery, gastroenterology and gastro-intestinal surgery, and urology.

vials and needles

Study examines severity of COVID-19 on kids with Type 1 diabetes

vials and needles

A new study published in the Journal of Diabetes, found that although nearly 80% of youth with Type 1 diabetes and COVID-19 infection are managed at home, youth from racial and ethnic minority groups – those with higher hemoglobin A1c values – and those with public insurance are at increased risk for hospitalization.

In a new study published in the Journal of Diabetes, researchers found that although nearly 80% of youth with Type 1 diabetes (T1D) and COVID-19 infection are managed at home, youth from racial and ethnic minority groups – those with higher hemoglobin A1c values – and those with public insurance are at increased risk for hospitalization. Most hospitalizations among these youth were related to diabetic ketoacidosis (DKA) (72%) and 86% of youth hospitalized had an A1c value over 9%. The increased risk for DKA among racial and ethnic minority groups and publicly insured youth in this study is indicative of disparities in T1D outcomes and aligns with other research findings both before and during the pandemic.

Adults with certain underlying medical conditions, like diabetes, are at an increased risk for severe illness from COVID-19. Though there are limited data on youth with T1D who have been infected with COVID-19, viral infections can make it harder to control blood glucose levels. If not properly managed, infections may lead to DKA, a serious life-threatening condition where the body converts fat instead of sugar into energy, causing ketones to build up in the blood and acid levels to rise.

“There is still more to learn about COVID-19 and how it affects children with diabetes and other underlying medical conditions,” said Brynn Marks, M.D., MS-HPEd, pediatric endocrinologist at Children’s National Hospital and one of the study’s co-authors. “We are hopeful that this latest data will emphasize the importance of optimizing glycemic control and give physicians and families more information about the virus and T1D so that severe illness and hospitalizations can possibly be prevented.”

In April 2020, the T1D Exchange Quality Improvement Collaborative, along with endocrinology clinics across the U.S., formed a COVID-19 clinical registry to better understand symptoms and outcomes of patients with T1D who also tested positive for SARS-CoV-2 infection. More than 46 centers nationwide, including Children’s National Hospital, submitted data to this novel registry of 266 youth under the age of 19 with previously established T1D and laboratory confirmed COVID-19.

The study found that nearly 80% of youth with T1D and known COVID-19 infection were cared for at home without any adverse outcomes. It is also important to note that COVID-19 was incidentally discovered in 16% of hospitalized youth admitted for reasons unrelated to COVID-19 or T1D (e.g. urological procedures, psychiatric admissions). However, the data revealed a disproportionate rate of hospitalizations and DKA among racial and ethnic minority groups, children who were publicly insured and those with higher A1c. Out of the 266 patients, 72% of the 61 patients were hospitalized due to DKA. An overwhelming majority (82%) of hospitalized patients had an A1c value greater than 9%. More than 40% of non-Hispanic Black youth in the study were hospitalized as compared to 14% of non-Hispanic white youth. Researchers also noted that those patients with public insurance were less likely to use insulin pumps and continuous glucose monitors, emphasizing the continued need to improve more access to diabetes technologies.

“Diabetes technology has advanced rapidly in the last decade and access to insulin pumps and continuous glucose monitors is improving, however these technological advances are perpetuating pre-existing disparities in T1D care and outcomes,” Dr. Marks said. “The data is clear and there is a pressing need to act to promote optimal care for all people with T1D.”

Recently, Dr. Marks and the Children’s National Diabetes team became official members of the Type 1 Diabetes Exchange Collaborative. The team looks forward to using the opportunity to improve diabetes care both here at Children’s National and across the country.

 

Gracie Popielarcheck

Raising awareness about Turner Syndrome

Gracie Popielarcheck

Gracie Popielarcheck was diagnosed at age one with Turner Syndrome.

By Roopa Kanakatti Shankar, M.D., M.S., Director of the Turner Syndrome Program at Children’s National Hospital.

The Children’s National  Turner Syndrome Clinic is part of the Division of Endocrinology and Diabetes which is ranked by U.S. News & World Report as one of the top 10 programs in the nation. The clinic opened in January 2019 and is the first of its kind in the Washington, D.C., region. A multidisciplinary clinic is held once a month with a team experts in cardiology, endocrinology, psychology, gynecology and genetics to help care for the needs of patients with Turner Syndrome all in one day. The referral network of specialties includes neuropsychology, otolaryngology, audiology, orthopedics, urology and dentistry.

Turner syndrome (TS) is a rare disease affecting girls, with a prevalence of around 25-50 out of every 100,000 females. It is caused by partial or complete loss of the second sex chromosome. This affects multiple organs and can cause heart defects, skeletal abnormalities, hearing loss and learning difficulties. It also affects growth and puberty and can cause infertility. Although the condition was first described in 1938 by Henry Turner, an endocrinologist from Oklahoma, and is well characterized, there is a significant delay in diagnosis and recognition of the condition, especially in milder forms that can still significantly impact the well-being of the individual.

Gracie Popielarcheck with a pet bird

“Having a Turner Syndrome clinic near our city has made life so much easier,” says Gracie’s mom, Leslie Popielarcheck. “We can see all of Gracie’s specialists all in one day and under one roof.”

Families often ask why it took so long to recognize this condition. Many findings can be subtle, the presentation can vary greatly and often short stature may be overlooked in some girls. We now recognize that the classic form (monosomy X) impacts less than half of the girls and the rest have mosaicism (45,X/ 46XX) or other structural abnormalities in the X-chromosome. Recognizing features beyond the classic “short stature, neck webbing, lymphedema and cardiac defects” is indeed important to get timely care for these girls and women across the lifespan. Many have recurrent ear infections and hearing loss. Most have a normal intelligence, and even superior verbal skills but face challenges in visual spatial perception, executive function, working memory and social cognition that impact academic achievement.

13-year-old Gracie Popielarcheck was diagnosed with TS at the age of one after her parents noticed a delay in her speech and development. “We had never heard of Turner Syndrome when Gracie was diagnosed,” says Leslie Popielarcheck, Gracie’s mom. “Gracie didn’t have the classic physical features that girls with Turner Syndrome are known to have.”

With support, most of these girls and women can manage the medical and psychosocial challenges and rise to their full potential. Advances in the field and multidisciplinary care models have helped in the establishment of TS clinics across the country that strive to improve the standard care for these girls.

However, several challenges remain:

  • Improving awareness among primary care physicians in regard to the extended spectrum and variability of presentation at a wide variety of ages
  • Decreasing health disparities and making multidisciplinary clinics and comprehensive care available and accessible even to disadvantaged communities
  • Ensuring adequate medical and social support for transition of young adults and care of adults with Turner syndrome
Gracie P., Kyra Dorfman with Dr. Shankar

Kyra Dorfman, Dr. Shankar and Gracie.

Our TS program, initiated 2 years ago, aims to overcome these challenges and provide care to families impacted by TS in our community. We strive to serve as a Regional Resource for the community as well as physicians in our community and have been recognized by the TSGA (Turner syndrome Global Alliance) as one of only nine clinics nationwide with a Level 4 designation.

“Having a Turner Syndrome clinic near our city has made life so much easier,” Popielarcheck says. “We can see all of Gracie’s specialists all in one day and under one roof.”

As we highlight these resources for the Turner Syndrome Awareness Month this February 2021, and celebrate the strength and tenacity of our beautiful girls, we hope our efforts will improve recognition of the condition and delivery of comprehensive medical care and support to the community we serve.

boy checking his blood glucose

There’s still more to learn about COVID-19 and diabetes

boy checking his blood glucose

Researchers have learned a lot about COVID-19 over the past year and are continuing to learn and study more about this infection caused by the SARS-CoV-2 virus. There have been many questions about whether COVID-19 affects people with diabetes differently than those without and why this might occur.

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population. Dr. Marks tells us more about what we know so far and further research that needs to be done when it comes to COVID-19 and diabetes.

1.      What do we know about COVID-19 and its effect on people with known diabetes?

The Centers for Disease Control and Prevention (CDC) currently lists type 2 diabetes (T2D) as a high risk condition for severe illness related to COVID-19 infection, while stating that adults with type 1 diabetes (T1D) might be at increased risk. A recent study from Vanderbilt University found that people with T1D and T2D were at approximately equal risk for complications of COVID-19 infection. As compared to adults without diabetes, adults with T1D and T2D were 3-4 times more likely to be hospitalized and to have greater illness severity. Given these comparable risks, both the American Diabetes Association and the Juvenile Diabetes Research Foundation are lobbying for adults with T1D to be given the same level or priority for COVID-19 vaccines as adults with T2D.

However, as pediatricians, we all know to be wary of extrapolating adult data to pediatrics. Children are less likely to be infected with COVID-19 and if they are, the clinical course is typically mild. To date, there have not been any studies of the impact of COVID-19 on youth with known T2D. Our clinical experience at Children’s National Hospital and reports from international multicenter studies indicate that youth with T1D are not at increased risk for hospitalization from COVID-19 infection. However, paralleling ongoing disparities in T1D care, African Americans with known T1D and COVID-19 infection were more likely to be develop diabetic ketoacidosis (DKA) than their White counterparts.

With the increased use of diabetes technologies, including continuous glucose monitors, insulin pumps and automated insulin delivery systems, diabetes care lends itself well to telemedicine. Studies from Italy during the period of lockdown showed better glycemic control among youth with T1D. Further studies are needed to better understand the implications of telehealth on diabetes care, particularly among those in rural areas with limited access to care.

Brynn Marks

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population.

2.      What do we know about the impact of the COVID-19 pandemic on children with newly diagnosed diabetes?

Nationwide studies from Italy and Germany over the first few months of the pandemic found no increase in the incidence of pediatric T1D during the COVID-19 pandemic as compared to the year before; in fact, the Italian study found that fewer children were diagnosed with T1D during the pandemic. However, many centers are seeing higher rates of DKA and more severe DKA at diagnosis during the pandemic, possibly due to decreased primary care visits and/or fears of contracting COVID-19 while seeking care.

To date, no studies have been published exploring the incidence of T2D in youth. A group from Children’s National, including myself, Myrto Flokas, M.D., Abby Meyers, M.D., and Elizabeth Estrada, M.D., from the Division of Endocrinology and Randi Streisand, Ph.D., C.D.C.E.S. and Maureen Monaghan, Ph.D., C.D.C.E.S., from the Department of Psychology and Behavioral Health, are gathering data to compare the incidence of T1D and T2D during the pandemic as compared to the year before.

3.      Can COVID-19 cause diabetes to develop?

This has been area of great interest, but the jury is still out. The SARS-CoV-2 virus, which causes COVID-19 infection, binds the angiotensin-converting enzyme 2 (ACE2) receptor which is located in many tissues throughout the body, including the pancreas. SARS-CoV-2 has been shown to infect pancreatic tissue leading to impaired glucose stimulated insulin secretion. Although the SARS-CoV-2 virus could plausibly cause diabetes, assessment has been complicated by many confounders that could be contributing to hyperglycemia in addition to or rather than the virus itself. Stress-induced hyperglycemia from acute illness, the use of high dose steroids to treat COVID-19 infection, and the disproportionate rates of infection among those already at high risk for T2D, as well as weight gain due to changes in day-to-day life as a result of social distancing precautions are all likely contributing factors.

woman writing data to medical form and glucometer for checking sugar level

New grant to assess screening tools for cystic fibrosis-related diabetes

woman writing data to medical form and glucometer for checking sugar level

A grant from the Cystic Fibrosis Foundation will help Children’s National researchers assess the feasibility and accuracy of two new cystic fibrosis-related diabetes screening tools.

Cystic fibrosis-related diabetes (CFRD) is the most common non-pulmonary manifestation of cystic fibrosis (CF), affecting up to 30% of adolescents and 50% of adults living with CF, according to the Cystic Fibrosis Foundation (CFF). CFRD is often asymptomatic and so the CFF recommends that people living with CF be screened for CFRD annually starting at 10 years of age using an oral glucose tolerance test.

Although early detection and treatment of CFRD can lead to significant clinical improvements and prolong life, rates of screening are poor, likely due to the burdensome nature of oral glucose tolerance testing (OGTT). Rates of OGTT screening in patients 10-17 years of age vary widely among CF care centers, ranging 5.9% to 100% with a median of 61.3% of patients at a given center completing screening. At Children’s National, only 46.4% of pediatric CF patients without CFRD completed the OGTT in 2019.  The most commonly cited reason for failure to complete recommended OGTT screening is the additional burden that this time-consuming fasting test, requiring three blood draws, places upon patients who already contend with multiple medical interventions.

“People living with CF face tremendous medical burdens.,” says Brynn Marks, M.D., MSHPEd, pediatric endocrinologist at Children’s National Hospital. “Novel, more convenient approaches to CFRD screening that can provide both diagnostic and therapeutic information are urgently needed.”

Dr. Marks and Carol Chace, MSW, a social worker at Children’s National, have collaborated to receive a $160,000 Pilot and Feasibility Award from the CFF that will allow researchers to assess the feasibility and accuracy of two new CFRD screening tools, the Dexcom G6 Pro, a continuous glucose monitoring (CGM), and the Digostics GTT@home, a home-based OGTT kit. The Dexcom G6 Pro is the first unblinded professional CGM that enables patients to see their glucose values and trends in real-time. The GTT@home uses a built-in timer and audio-visual cues to guide users to collect capillary blood samples through finger sticks.

“While the idea of home-based testing is exciting in general, it is particularly important in the midst of the COVID-19 pandemic, as many are limiting preventative health care visits,” says Dr. Marks. “This research will hopefully inform future larger studies that could one day allow for this screening to be done at home.”

iLet-Bionic-Pancreas

Children’s National to test bionic pancreas

iLet-Bionic-Pancreas

The iLet bionic pancreas helps patients manage their diabetes by both monitoring blood glucose levels and administering insulin and glucagon.

The final results of this clinical trial were published on September 29, 2022 in the New England Journal of Medicine.

Children’s National Hospital has been selected to participate in a multi-center clinical trial to test the efficacy of the iLet bionic pancreas — a device that automatically regulates blood sugar levels in patients with Type 1 diabetes.

Patients generally manage diabetes by constantly monitoring their blood sugar levels and administering insulin when necessary. Unfortunately, too much insulin can cause hypoglycemia, or low blood sugar, which can result in hypoglycemic seizures, coma or rarely, death. Thus, it is extremely important for people with diabetes to regulate their insulin dosages and maintain their blood sugar levels within a range decided by the family and diabetes team.

“The burden of caring for diabetes on a daily basis is grueling,” says Seema Meighan, FNP, a nurse practitioner involved in the upcoming clinical trial. “It is by far one of the most challenging chronic diseases to manage, and requires vigilant participation 100 percent of the time to stay well controlled.”

The iLet bionic pancreas helps patients manage their diabetes by both monitoring blood glucose levels and administering insulin and glucagon — a pancreatic hormone that raises blood sugar levels.

“In a traditional infusion pump, patients only have access to insulin to control glucose levels,” explains Meighan. “This can become problematic when it comes to hypoglycemia. The hope with a bi-hormonal system is that glucagon can be delivered during times that the glucose is low in order to stabilize levels without user interaction.”

Developed at Boston University by Edward Damiano, Ph.D., and Firas El-Khatib, Ph.D., the iLet is a hand-held device about the size of an iPhone but twice as thick, and can easily fit into a pocket. The unit consists of a dual chamber infusion pump that can be configured to deliver only insulin, only glucagon or both hormones. The device uses a wireless glucose sensor on the patient’s body to test blood sugar levels every five minutes. It then determines which hormone is needed and administers it via catheters connected to the patient.

In short-term studies, the iLet was able to maintain blood glucose levels close to normal in both adults and children in carefully controlled environments.

In 2016, the Children’s National Hospital Division of Endocrinology and Diabetes, led by diabetologist Fran Cogen, M.D., C.D.C.E.S., was one of several pediatric sites that were selected to participate in pivotal clinical trials to further test the efficacy of the bionic pancreas. In June 2020, the team at Children’s National began enrolling patients to test iLet devices that only deliver insulin. Once these initial studies are completed, the team will perform an additional trial to test iLet devices configured to deliver both insulin and glucagon.

“This trial is important as it represents the first dual chamber pump to manage glucose levels,” says Meighan. “It could potentially change the way we treat diabetes entirely. It represents a hope to our patients and families that one day this disease will have far less of a daily burden than it currently does.”

Currently, there are 18 patients enrolled in the clinical trial. An initial test run on two patients was successfully completed in November 2020. In early January 2021, the first patient was started on the bionic pancreas to begin the randomized controlled study and three additional patients, who completed the screening process, will join the study shortly. The screening and initiation of the study will continue in the remaining patients.

Lee Beers

Lee Beers, M.D., F.A.A.P, begins term as AAP president

Lee Beers

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Lee Savio Beers, M.D., F.A.A.P., medical director of Community Health and Advocacy at the Child Health Advocacy Institute (CHAI) at Children’s National Hospital, has begun her term as president of the American Academy of Pediatrics (AAP). The AAP is an organization of 67,000 pediatricians committed to the optimal physical, mental and social health and well-being for all children – from infancy to adulthood.

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Dr. Beers has pledged to continue AAP’s advocacy and public policy efforts and to further enhance membership diversity and inclusion. Among her signature issues:

  • Partnering with patients, families, communities, mental health providers and pediatricians to co-design systems to bolster children’s resiliency and to alleviate growing pediatric mental health concerns.
  • Continuing to support pediatricians during the COVID-19 pandemic with a focus on education, pediatric practice support, vaccine delivery systems and physician wellness.
  • Implementation of the AAP’s Equity Agenda and Year 1 Equity Workplan.

Dr. Beers is looking forward to continuing her work bringing together the diverse voices of pediatricians, children and families as well as other organizations to support improving the health of all children.

“Dr. Beers has devoted her career to helping children,” says Kurt Newman, M.D., president and chief executive officer of Children’s National. “She has developed a national advocacy platform for children and will be of tremendous service to children within AAP national leadership.”

Read more about Dr. Beer’s career and appointment as president of the AAP.

Drs. Dewesh Agrawal, Andrew Dauber, Robert Freishtat, Vittorio Gallo

Four Children’s National Hospital leaders named to APS

Drs. Dewesh Agrawal, Andrew Dauber, Robert Freishtat, Vittorio Gallo

Drs. Dewesh Agrawal, Andrew Dauber, Robert Freishtat and Vittorio Gallo were named as 2021 American Pediatric Society members.

The American Pediatric Society (APS) has announced 55 new members, four of which are experts from Children’s National Hospital. Founded in 1888, the APS is the first and most prestigious academic pediatric organization in North America.

APS members are recognized child health leaders of extraordinary achievement who work together to shape the future of academic pediatrics. New members are nominated by current members through a process that recognizes individuals who have distinguished themselves as child health leaders, teachers, scholars, policymakers and/or clinicians.

“Our members represent the most distinguished and accomplished academic leaders in pediatrics whose outstanding work has advanced child health,” said APS President Steven Abman, M.D. “I am honored to welcome this exceptional group of individuals to the APS. The APS is especially looking forward to the active engagement of our membership with many exciting programs within the organization that are directed towards improvements in academic pediatric medicine, including more vigorous approaches to express our values of anti-racism, equity, diversity and inclusion.”

APS 2021 active new members from Children’s National are:

  • Dewesh Agrawal, M.D., vice-chair for Medical Education at Children’s National. Agrawal’s career has been marked by academic honors and teaching awards at every stage of his training and faculty employment. He has relentlessly devoted his energy to improving the educational experience for students, residents and fellows at Children’s National.
  • Andrew Dauber, M.D., M.M.Sc., chief of Endocrinology at Children’s National. Dr. Dauber’s leadership is reflected, nationally and internationally, in his ability to create research consortia, bringing together investigators to tackle complex questions. For example, he leads an NIH-funded consortium on the genetics of short statures, with multiple top children’s hospitals as partners. He also leads a large clinical trial testing a novel therapeutic agent for genetic short stature.
  • Robert Freishtat, M.D., M.P.H., senior investigator in the Center for Genetic Medicine of the Children’s National Research Institute (CNRI). Dr. Freishtat has authored or co-authored more than 100 articles and book chapters in the fields of pediatric lung injury, asthma, obesity, exosomes and emergency medicine. His research has been continuously funded by the NIH since 2003.
  • Vittorio Gallo, Ph.D., chief research officer at Children’s National and scientific director of CNRI. Dr. Gallo’s scientific success is attested to by over 130 peer-reviewed publications, many in very high-profile journals, as well as over 30 review articles and book chapters. He has received many national and international awards, including the NINDS Javits award in Neuroscience in 2018. Dr. Gallo has served on the editorial boards of many neuroscience journals, including Glia and the Annual Review in Neuroscience, and has been reviewing editor for the Journal of Neuroscience, all of which is a testament to the tremendous impact that his studies have had on the advancement of neurosciences.

“These new members represent multiple areas of Children’s National and have all leveraged the intersection of science, medicine and clinical education to make advances in their field of study,” said Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National. “Their work has, and will continue to, advance pediatric health care, and I congratulate them on their APS membership.”