Caring for Pediatric Patients with Diabetes amidst the COVID-19 Storm

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Coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome (SARS-CoV-2) virus is a rapidly progressing pandemic with more than 2.5 million infected cases worldwide and WHO estimated mortality rate of 6.9% at the time of writing. As clinicians, it is imperative that we keep ourselves informed of the daily emerging scientific evidence in order to understand the impact of COVID-19 on our patients, particularly those belonging to a high-risk group, such as the diabetic population.

Although the evidence to date have shown that children are generally less prone to COVID-19 infection with those infected tending to have a milder disease course, children with existing comorbidities continue to remain highlighted as at risk group.1x[1]Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta paediatrica (Oslo, Norway : 1992). 2020.
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The main strategy in reducing the risk and severity of the SARS-CoV-2 infection in diabetic children is to optimize glycemic control. In addition, the general recommendations for infection prevention cannot be emphasized enough during this pandemic. All diabetic patients should receive pneumococcal and influenza vaccinations and be specifically reminded about the importance of good hand hygiene, avoiding touching their faces, and observing appropriate social distancing to reduce risk of infection. We echo the specific recommendations outlined by Gupta et al for diabetic patients infected with SARS-CoV-2.3x[3]Gupta, R., Ghosh, A., Singh, A.K., and Misra, A. Clinical considerations for patients with diabetes in times of COVID-19 epidemic. Diabetes & metabolic syndrome. 2020;
14: 211–212
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Notably, diabetologists should pay attention to recent reports on the use of angiotensin converting enzyme (ACE)-inhibiting agents in patients with COVID-19, as many diabetic patients including children are receiving this medication for albuminuria. Although there is some suggestion that ACE-inhibitors may increase the severity of COVID-19, reports are conflicting suggesting both increased ACE level may be a poor prognostic factor for severe pneumonia and that use of ACE-inhibiting agents reduce the severity of pulmonary inflammation.4x[4]Bavishi, C., Maddox, T.M., and Messerli, F.H. Coronavirus Disease 2019 (COVID-19) Infection and Renin Angiotensin System Blockers. JAMA cardiology. 2020;

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It is important for clinicians to be cognizant of the possibility of delayed presentation of new cases of type 1 diabetes, as parents may delay medical attention for their children due to fear of exposure to infection in emergency services. Moreover, parents of children with suboptimal diabetic control who require closer follow up may postpone their appointments due to fear and anxiety. Where available, these patients should be offered the option of remote teleconsultation with their doctors to review their glycemic control and insulin titration, especially for young children. With many countries instituting policies to mandate home quarantine, clinicians also should be mindful of the potential of changes in dietary habits and available food choices as well as reduction in physical activity, which impact glycemic control.

There has been advancement in technologies now available commercially to aide diabetes management including telehealth monitoring technologies, diagnostic tools, and monitoring kits. Amidst this COVID-19 crisis, endocrinologists can exploit these systems and devices to provide remote care to their patients with diabetes. The use of continuous glucose monitoring systems (CGMS) is now the standard of care in many centers worldwide. Closed-loop CGMS systems that incorporate the use of automated decision support systems between insulin pumps and CGMS provide an added benefit, which is that insulin titration can be achieved accurately with good comparability to endocrinologist-decision making.6x[6]Nimri, R., Dassau, E., Segall, T., Muller, I., Bratina, N., Kordonouri, O. et al. Adjusting insulin doses in patients with type 1 diabetes who use insulin pump and continuous glucose monitoring: Variations among countries and physicians. Diabetes, obesity & metabolism. 2018;
20: 2458–2466
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Although we are learning more about SARS-CoV-2 by the day, there remain many grey areas and uncovered blind spots, some of which may apply to diabetic children. It is essential that we keep ourselves updated on the continuous stream of information that may concern our patients. As healthcare providers caring for these vulnerable patients, our role and commitment to them remains unbroken. We should continue to provide diabetes care through the safest possible way, and remain accessible to our patients, either through telehealth platforms or specifically planned face-to-face visits that would incorporate measures to minimize risk of infection to the patients and the healthcare team.

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