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Endocrinology, Inside Pediatrics

High-Risk Diabetes Clinic Keeps Kids Out of the Hospital

Children’s of Alabama offers clinic to help high-risk diabetes patients.

The 2018 death of a teenage patient was a wake-up call for Children’s of Alabama pediatric endocrinologist Mary Lauren Scott, MD. The patient had type 1 diabetes and had been admitted numerous times over the previous few years with sky-high blood sugar. He died at home from diabetic ketoacidosis (DKA), a diabetic emergency in which the body breaks down fat for fuel because it doesn’t have enough insulin.

In response, Scott, who also has type 1 diabetes, took action. She and her team searched their data and found 10 patients in the previous year who had been admitted three or more times with DKA. Such admissions are a red flag that the patient isn’t taking their insulin doses at home and that they have a risk of dying or having a medical emergency they can’t recover from. 

“When you’re dealing with a chronic disease such as diabetes and patients have recurrent hospitalizations, we get burnt out too,” she said. “That makes it difficult to have the kind of positivity, motivation and drive to help them surmount the insurmountable and deal with what, for them, feels impossible. It’s hard, it’s complicated, and it’s not uplifting when you feel like you’re not able to help the patient.”

Scott, who was already directing a clinic for children and adolescents with type 2 diabetes, started another clinic in 2018 specifically for these high-risk patients. The primary goals of the clinic are to prevent hospitalizations and saving lives. The patients are all adolescents, at an age when they—instead of their parents—typically start handling their insulin injections and blood glucose tracking. 

The clinic meets half a day each month. The focus is on communication. Parents, social workers, nurses, nurse practitioners, diabetes educators and counselors work as a team to build trust with the teenagers. “We speak to them differently to get them to open up to us more than they perhaps ever have with other providers,” Scott said.

That means ensuring them there is no shame attached to missing insulin doses; what’s important is that they talk about it. “We tell them, ‘We need to know how to help you, so we can help you find success,’” Scott said. “We try to make the focus more about what’s working for [them] with [their] diabetes, what’s not working, and what [they] think would make things easier.” 

Patients must go six months without hospitalization before they graduate from the program.

The clinic is not just for patients, but for their families, as well. The patients are often drawn from minority and low-income backgrounds and have single parent households, Scott said. “The parent works and is also trying to manage a teenager who’s depressed or burnt out,” she said. “They can’t do everything.”

Because many of the parents have a history of interaction with child protective services, they rarely opened up to the staff about their child’s difficulties. With the new approach, parents are now more likely to talk about what’s happening at home and what they need help with. “That’s where we typically find success for these patients,” she said. 

The results have been impressive. 

  • 14 of the original 15 patients graduated. The one remaining is the youngest patient with significant home life issues. 
  • 8 of the 14 had a lower A1C when discharged. 
  • 6 of the 14 had no DKA admissions while in the clinic; all had three or more before joining the clinic. 
  • 12 of the 14 had fewer missed visits even though they came to clinic monthly instead of every three to four months.
  • Half had lower rates of DKA.
  • 12 of the 14 started continuous glucose monitoring while in clinic, and four also received insulin pumps, leading to a dramatic improvement in their health.
  • No patients died.

There are currently eight more patients enrolled, and more will be invited in the coming months, Scott said.

Endocrinology, Inside Pediatrics

PCOS Clinic Provides Holistic Care with a Multidisciplinary Approach

Doctor speaking with patient.

Excessive weight gain, acne, hirsutism, thinning hair, irregular menstrual cycles and insulin insensitivity –  these are some of the symptoms of polycystic ovary sydrome (PCOS), the most common reproductive condition in women and a risk factor for a plethora of metabolic diseases, including diabetes and cardiovascular disease, as well as infertility. It affects between 3% and 15% of women, who often wait years for a diagnosis, visiting numerous clinicians in the process.[i]

That’s changed for the young women of Alabama since pediatric endocrinologist Christy A. Foster, MD, started a multidisciplinary clinic in 2020 for adolescents with PCOS.

“Our goal is to try to improve the care patients receive in a more holistic manner,” she said. The clinic’s foundation is a multidisciplinary team that includes Foster, a pediatric gynecologist, a dermatologist, a social worker and family counselor, and a nutritionist. 

Many of these young women have been seen multiple times by their primary care doctor before they’re referred. “Coming to the clinic enables them to put a voice to what’s wrong—a feeling that they’re understood—which can be helpful,” Foster said. The multidisciplinary approach also provides expertise from several different providers. “That certainly helps with their care because otherwise they might have to make several different appointments and take more time to travel.” And most are just glad to have a home with providers who have expertise with PCOS. 

The physical manifestations of PCOS create a challenge at a particularly difficult time for young women, Foster said. “Their peers notice they ‘look different,’” she said. “That’s certainly a challenge for them from a mental health perspective.” That’s why it’s so important that the team includes counseling and mental health.

The Children’s clinic is one of only a limited number in the country, which is one reason Foster felt strongly about starting it. “I wanted to improve access to care in our region and address the patient as a whole person,” she said.

The team tailors treatment to address the patient’s greatest concerns, be it pre-diabetes, facial hair, severe acne or other repercussions of PCOS. “My hope is that when we start them on treatment, they feel their concerns are being addressed and heard and understood,” Foster said. Treatment options include birth control pills to regulate their menstrual cycles, an insulin sensitizer such as metformin, laser hair treatment and androgen receptor blockers. 

Another advantage of the clinic is that the team can follow the women longitudinally and, hopefully, prevent some of the metabolic conditions they’re at risk for.

After clinic, the team holds a debrief to discuss the patient as a whole, “There is a benefit to having everyone in the same place,” Foster said. “It improves communication.”

The clinic is held once a quarter, although patients may see individual providers at other times. Since it began, about 50 young women have been seen, with about six to eight seen during each half-day clinic. “But certainly we’re looking to grow,” Foster said.

[i] Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2017;102(2):604-612. doi:10.1210/jc.2016-2963

Endocrinology, Inside Pediatrics

Managing Congenital Adrenal Hyperplasia With Precision

Nurse practitioner Leslie Pitts (left) and Dr. Gail Mick, director of the Children’s of Alabama endocrine newborn screening program.

Congenital Adrenal Hyperplasia (CAH)—a group of rare genetic disorders affecting the adrenal gland—occurs in approximately 1 in 16,000 children each year, and these rare cases present significant challenges for patients, parents and doctors. Without proper treatment, it can be a life-threatening condition, but treating it can be difficult for doctors. That’s why the endocrine team at Children’s of Alabama is participating in an international pediatric, phase 2 trial called CAHtalyst to investigate a new nonsteroidal treatment.

The treatment, Crinecerfont, may improve adrenal hormone balance by tamping down excess androgen production. The drug has already shown efficacy and safety in adult CAH trials, and Gail J. Mick, MD, director of the Children’s endocrine newborn screening program, says she’s delighted that Children’s can participate in the study. “The families are excited about new CAH research because they want new therapeutic options,” she said. 

CAH, which can occur in multiple forms, affects the adrenal gland’s ability to produce cortisol, a hormone critical for life; and aldosterone, a hormone that regulates salt and water balance. The most common form of CAH occurs due to a deficiency of the adrenal enzyme 21-hydroxylase. Without this enzyme, affected individuals are at risk of a life-threatening adrenal crisis as well as adrenal androgen overproduction. 

Doctors in the Children’s of Alabama’s endocrine newborn screening program specialize in helping newborns with CAH, which is one of more than 30 disorders screened for at birth by Alabama’s newborn screening program. At Children’s, newborns who screen positive for CAH are immediately evaluated for emergency care and management. To help parents and children with CAH, the Children’s Division of Endocrinology and Diabetes provides comprehensive care to nearly 100 CAH patients per year.

Treatment involves infusions of steroids and fluids, followed by carefully titrated doses of cortisol and mineralocorticoids. It’s not always easy. “It’s a very delicate balance to mimic normal adrenal function with oral medications,” Mick said. Give too much glucocorticoid, and you can suppress growth and expose patients to adverse steroid side effects. Give too little, and the adrenal gland overproduces androgens, which can spur early puberty and excess growth as well as other complications.

The adrenal imbalance is even more complex when children are sick and can’t take their medications. In those cases, parents must administer injectable glucocorticoids and seek emergency medical care. For this reason, routine childhood illnesses put a tremendous strain on parents. 

Extra support is essential, Mick says. CAH is challenging to manage, given individual nuances in adrenal insufficiency and the impact of growth and puberty on medical management.  “We offer special teaching and support for the parents in those early years as far as understanding how and when to give steroids and hormones to prevent adrenal crisis,” said nurse practitioner Leslie Pitts MSN, AC-PNP, CDE. 

The CAH and endocrine newborn screening clinic also serves as an important resource for pediatric providers throughout the region. “Providers consult with us when they have abnormal newborn screens on their patients,” Pitts said. “They know we’re available to answer questions and concerns regarding CAH diagnosis and management.”

Pitts and Mick stress the key role that parents play in managing their child’s CAH. “Hats off to the families of children with CAH,” Mick said. “They are a motivated community who support one another, advocate for CAH research and treatment, and have even put together a highly popular ‘Camp Cortisol’ at Children’s Harbor at Lake Martin.” 

“These are really quite extraordinary families,” Pitts said. And they may have a brighter future thanks to clinical trials like CAHtalyst. Mick predicts that in the next couple of years, they’ll have access to many more treatment options that will make the condition easier to live with.