Three messages regarding COVID-19 & pediatric endocrinology

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A reassuring note: The healthcare community is learning more about the effects of COVID-19 on specific patients. You may have read that diabetes is a risk factor for severe COVID-19. Please know however that this data regards adults, mainly older adults. On March 25th, our European colleagues reported their impression that pediatric-aged patients with diabetes are not at increased risk of severe COVID-19. Likewise, initial data reports from the US have not mentioned diabetes as a pediatric-aged risk factor. On May 29, a peer-reviewed French scientific article reported similar findings. See this blog post for more details. It would be reasonable to assume the same is likely true for pediatric-aged patients with various endocrine disease, though we have yet to see any data. In any case, it remains important to be careful with your diabetes and endocrine medications. For youth with diabetes, aim to control your blood sugars as best possible, make sure to take your long-acting insulin / keep you insulin pump in good working order. For youth with adrenal insufficiency, make sure to take your prescribed hydrocortisone or other steroids, and give stress dose steroids if ill etc as instructed. Keep your prescriptions up. Be sure to minimize exposures, practice social distancing, frequent hand washing, etc. See our hospital COVID-19 website for additional information.


We remain available 24/7: Please know that we are here for our patients. If you have questions or concerns about managing your endocrine condition, please contact us by phone/email/fax. If you are ill and might benefit from endocrine advice, we will work hard with you over the phone to help keep you from needing to come to the hospital. As of May 4, we have carefully re-opened our outpatient clinic for routine visits, in accordance with policies set by the State of Iowa. Additionally, we can conduct selected routine visits not requiring physical examination via video-chat. Contact us and we will help you arrange a clinic visit. Further information can be found at our official clinical website.


COVID-19 increases risk of DKA: Data has now been published showing that many persons with type 1 diabetes who develop COVID-19 will develop diabetic ketoacidosis (DKA). Our summary of the study can be found here (link). If you or your loved one has type 1 diabetes, and develops symptoms of COVID-19, be sure to contact your diabetes doctor to help provide advice on how to prevent DKA. Fluids, carbohydrates, ketone checks, and extra insulin are very important in this regard. We remain on call 24×7 to assist.

Primary Adrenal Insufficiency Might Worsen COVID-19 Risk

Andrew Norris, MD PhDPost by
Andrew Norris, MD PhD
Director, Pediatric Endocrinology & Diabetes
University of Iowa Stead Family Children’s Hospital

An important, timely question regards determining which co-existing conditions increase the severity of COVID-19 in youth. In adults, for example, obesity, metabolic syndrome, and type 2 diabetes are endocrine conditions that increase the risk of severe COVID-19. By contrast, it appears that diabetes in the young does not increase the risk of severe COVID-19 infection, as noted in our other blog post (link). In fact, most most pediatric endocrine conditions are not thought to induce immunosuppression. However, disorders of glucocorticoid secretion bear closer scrutiny. Excess glucocorticoid secretion, otherwise known as endogenous Cushing Syndrome, induces immunosuppression and may increase risk of severe COVID-19 (link). Thankfully, endogenous forms of Cushing Syndrome are very rare in children. However, deficiencies of glucocorticoid secretion (otherwise known as adrenal insufficiency) are not as rare and affect scores of youth in our region. The American Association of Clinical Endocrinologists (AACE) has published a position piece (link) warning that persons with adrenal insufficiency appear to be at higher risk of death from a wide swath of respiratory infections, and that there is no reason to suspect that this risk does not extend to COVID-19. Indeed, multiple large cohort / population studies have shown that persons with adrenal insufficiency have increased susceptibility to a wide swath of infections (example publications: 2020 JCEM ; 2013 JCEM ; 2016 JCEM ; 2006 JCEM ; 2017 EuJEndo ). It is important to note that there are at least two limitations to this “best available” evidence. (1) It has not involved youth with adrenal insufficiency. (2) Despite these studies being very large, they are largely retrospective. On the other hand, the observation is biologically plausible, since cortisol is a powerful immune modulating hormone that can not be replaced in a perfectly physiological manner. Thus, the related recommendations of the AACE appear important: briefly that persons with adrenal insufficiency should maintain precautions to avoid COVID-19 exposure, to maintain their adrenal replacement therapies, and to give stress dose steroids as instructed. The AACE recommendations can be found here. As always, our pediatric endocrinology team remains available 24/7 to support youth with adrenal disorders.

Announcing New Faculty: Eirene Alexandrou, MD

Dr. Alexandrou

We are pleased to announce that Dr. Eirene Alexandrou is starting as a new pediatric endocrinologist in our division. She received her Medical Degree from Indiana University School of Medicine, completed a residency in pediatrics at the Medical College of Georgia, and just completed a fellowship in pediatric endocrinology at the prestigious Cincinnati Children’s Hospital. She has published expertise in the areas of growth research (link) and Turner Syndrome. In clinic, her initial practice will include general pediatric endocrinology and diabetes, as well as outreach services in Cedar Rapids and Dubuque.

Announcing new faculty: Akhila Ramakrishna, MD

Dr. Ramakrishna

We are pleased to announce that Dr. Akhila Ramakrishna is starting as a new pediatric endocrinologist in our division. She received her Medical Degree from the Armed Forces Medical College, then completed a residency in pediatrics at Case Western Reserve, and just completed a fellowship in pediatric endocrinology at the prestigious Mayo Clinic. She has published expertise in the area of thyroid dysfunction (link) and has studied rodent models of obesity as a fellow as well. In clinic, her practice will include general pediatric endocrinology and diabetes, as well as gender-related endocrine care, obesity-related endocrine care especially regarding bariatric surgery in adolescents, and outreach pediatric endocrine services in Cedar Falls.

Announcing new faculty: Catherina Pinnaro, MD

Dr. Pinnaro

We are pleased to announce that Dr. Catherina “Cat” Pinnaro is starting as a new pediatric endocrinologist in our division. Her position will be on the tenure-track, meaning that she will be expected to be productive as a research physician. Dr. Pinnaro received her Medical Degree from New York Medical College where she successfully competed for a Doris Duke research year, which she spent at the University of Iowa. She then completed a residency in pediatrics at the University of Iowa, just completed a fellowship in pediatric endocrinology here as well, and is on track to earn a Master’s in Translational Biomedicine in late 2020. While a fellow, she has created several productive research projects, having already published on the genetics of 22q syndrome (link) and diabetes care simulation (link). Her research will focus on the etiology of diabetes in specific disease contexts, applying her genetics expertise. In clinic, her practice will include general pediatric endocrinology and diabetes.

COVID-19, Type 1 Diabetes, and Diabetic Ketoacidosis (DKA)

diabetic ketoacidosis (DKA) was a complication in almost half of cases among those with a positive COVID-19 test

Very early during the COVID-19 pandemic it was reported that diabetes was an apparent risk factor for severe disease and poor outcomes. These data came from populations where most of those with diabetes had type 2. So one question was the effect of type 1 diabetes on COVID severity. Now a study has been published examining the effects of type 1 diabetes on COVID. A total of 33 persons across the United States with type 1 diabetes and COVID-19 confirmed by PCR test were surveyed. Another 31 with suspected COVID were also identified. The average age was 24.8 years. The symptoms of COVID were similar to expectations including fever, cough, fatigue, vomiting, shortness of breath, and aches. Interestingly, hyperglycemia was sometimes one of the earliest symptoms. Importantly, diabetic ketoacidosis (DKA) was a complication in almost half of cases among those with a positive COVID-19 test. This suggests that COVID-19, like some other viral infections such as severe influenza, can precipitate DKA. The research was published June 5th in the journal Diabetes Care (find the article at link1 or link2 ). If you or your loved one has type 1 diabetes, and develops symptoms of COVID-19, be sure to contact your diabetes doctor to help provide advice on how to prevent DKA. Fluids, carbohydrates, ketone checks, and extra insulin are very important in this regard. We remain on call 24×7 to assist.

Announcing New Pediatric Endocrine Fellow: Dr. Tuttle

Dr. Tuttle

Today we are thrilled to announce that Dr. Alex Tuttle has joined our division as a pediatric endocrine fellow. He will serve three years in this role, after which he will be a full fledged board eligible pediatric endocrinologist. Dr. Tuttle received his Medical Degree from Indiana University. He then completed a pediatric residency at the University of Iowa Children’s Hospital. While a resident he demonstrated an aptitude for and interest in pediatric endocrinology, and was highly involved in diabetes camp (see picture below) at Camp Herkto Hollow and helped report an unusual pediatric endocrine case related to thyroid eye disease (link). Welcome Dr. Tuttle!!

Diabetes Camp Hertko Hollow: some of the volunteer staff from teen week 2019. Division members include Diabetes Nurse Sue Huff on the far left and (now) endocrine fellow Dr. Alex Tuttle on the far right.

Dr. Pinnaro Completes Pediatric Endocrine Fellowship

Dr. Pinnaro

We are extremely proud of Dr. Catherina “Cat” Pinnaro. For the past 3 years, Dr. Pinnaro has been a pediatric endocrinology fellow. Today she finishes this training, and will officially become a “board eligible” pediatric endocrinologist. During these three years, Dr. Pinnaro has been an exemplary fellow, providing outstanding clinical care, highly commended clinical teaching, and published research. She won several national awards as a fellow, including the Rising Star award from the Pediatric Endocrine Society, and the Leona Cuttler Quality Assurance Award from the American Academy of Pediatrics. We will miss her energetic approach to everything a fellow does. Following fellowship, Dr. Pinnaro has accepted a tenure-track position at a major research university where she continue her pediatric endocrine research related to diabetes, and will also continue her clinical work in pediatric endocrinology — stay tuned…. Congratulations Dr. Pinnaro!

Last Day for Dr. Sandberg

Dr. Sandberg

Today we are saddened to say goodbye to our colleague Dr. Beth Sandberg. She has been a stalwart colleague for the past year, providing compassionate and expert pediatric endocrine care. Dr. Sandberg joined our division last summer having just completed a fellowship in pediatric endocrinology at the University of North Carolina. While here, she provided general endocrine care, including outreach services in Cedar Falls, and gender-related endocrine care. The Pediatric Endocrine Society recognized her expertise and commitment by placing her as a national special interest group co-leader this year. After leaving Iowa, she will be taking a position in the Division of Pediatric Endocrinology at the University of Michigan / Mott’s Children’s Hospital. We send our best wishes to Dr. Sandberg for her move and new position.

Guest Lecturer – David Breault MD PhD

David Breault, MD PhD

We were graced today by a research talk from David Breault, MD PhD. Dr. Breault is an Associate Professor at Harvard Medical school and is the Associate Chief of the Division of Endocrinology at Boston Children’s Hospital. He spoke at our Frontiers in Pediatric Research seminar series manged by the Department of Pediatrics. Dr. Breault is an expert in the study of stem cells and lineage development, especially as relates to endocrine system. He received his MD and PhD from the University of Connecticut, completed pediatric residency at Yale, and a pediatric endocrinology fellowship at Boston Children’s Hospital. He is a physician scientist and directs a stem sell research laboratory funded by the NIH. His research has earned several prestigious awards including the election to the American Society for Clinical Investigation, and a Presidential Early Career Award for Scientists and Engineers receive at the White House. Dr. Breault spoke today on stem sell lineage development in the intestine and endocrine system.

Watching the Brain Remember: Differences Between Children with and without Type 1 Diabetes

With the advent of techniques to strengthen brain regions, such as transcranial magnetic stimulation, it is possible that this type of research will help delineate important future interventions.” –Andrew Norris

Dr. Tansey

Dr. Tansey and collaborators across the country have been studying brain function in children with and without type 1 diabetes. In a study published today (link) in the prestigious journal Diabetes, they report important differences between these two groups. They used functional magnetic imaging resonance (fMRI) to measure activation in various brain locations while the children were given memory tasks. Compared to children without diabetes, those with type 1 diabetes exhibited decreased memory performance relative to children without diabetes. Interestingly the children with type 1 diabetes showed greater increases in brain activation with harder tasks than those without diabetes, suggesting that their brains were working harder to compensate. More research is needed to understand how these effects of diabetes occur and how they might be modulated. With the recent advent of techniques to strengthen brain regions, such as transcranial magnetic stimulation, it is possible that this type of research will help delineate important future interventions. Also involved in the study from our Division were Dr. Tsalikian, Julie Coffey, Joanne Cabbage, Sara Salamati, and Rachel Bisbee.