Endocrine Disease
Obesity
During the COVID-19 pandemic, the pediatric population was mildly affected by the
virus itself, however, children’s lives were profoundly disrupted.
Children were subjected to home confinement and alterations in eating behaviors
and lifestyle modifications. The implementation of measures, such as social
distancing, closure of schools, nurseries and sports facilities, not only
promoted an unprecedented psychological burden in children, including anxiety
and loneliness [5], but also a change in
weight dynamics. Worsened dietary habits associated with increased snacking,
higher consumption of ultra-processed and preserved food due to fear of food
shortage or financial difficulties [6]
were documented.
In addition, physical activity was declined in favor of sedentary behavior due to
prolonged school closure, attendance of school lessons remotely, and restriction
of children’s regular, physical, extracurricular and outdoor activity
[7]. Excessive screen time also
resulted in sedentary behavior and snacking, which caused further reduction in
energy expenditure and an escalation of pediatric overweight and obesity [8]. “Covibesity” is a new
term that has been introduced and reflects the aggravation in obesity rates
during the pandemic [9].
During the pandemic, weight gain was reported in 25–41.7% of
adolescents from different countries [10]
[11]. Several studies have
reported an increase in food intake resulting in weight gain [10]
[12]. A study from Palestine showed that 41.7% of adolescents
gained weight due to increased consumption of fried food, carbohydrate-rich
food, and dairy products [11]. In a study
from China, children and adolescents of all age groups exhibited weight gain
[10]. Similar results were shown in a
study from Poland, according to which reduced vegetable, fruit, and legume
consumption during the pandemic was associated with an increase in BMI [13], as well as in a study from Italy [14]. A registry-based study of
approximately 150 000 children in Germany exhibited an exceptional aggravation
of BMI-SDS, which was increased by more than 30 times, after the
COVID-19-induced measures, particularly in children already affected by
overweight or obesity [8]. The seasonal
variation in BMI z-score was also affected during the COVID-19 pandemic in a
Korean population; as opposed to the previous years, BMI z-score was increased
even in spring [15].
Weight gain during the summer holidays is well known and a proportionate increase
in childhood obesity rates to the duration of school closure has been proposed.
This has been attributed to obesogenic behaviors during less structured days
[16]. An association between
overweight/obesity rates and economic crises or natural disasters has
also been established [17]
[18]. Similarly to previous findings, it has
been reported that during the COVID-19 pandemic limited purchasing access to
nutrient-dense foods (e. g., fresh fruits and vegetables) has led
families to buying high-calorie foods, such as sweets, desserts, sugary drinks,
or canned food [12]. During the pandemic,
in the US the percentage of families with difficulty accessing food increased by
20% due to financial reasons, closed stores, or the fear of transmitting
the virus [12].
The finding of increased obesity rates during the pandemic is of major importance
knowing that childhood obesity, an epidemic on its own, is likely to persist
into adulthood and that earlier onset is associated with more severe sequelae
related to comorbidities including hypertension, impaired glucose metabolism,
increased cardiovascular risk, depression or cancer [19]. Therefore, the importance of healthy
nutritional behaviors during the COVID-19 pandemic has been underlined [20].
Pre-existing obesity
Obesity has been recognized as one of the most prominent risk factors for severe
COVID-19, hospitalization and increased mortality in adults, but also in
children [20]. According to the CDC,
obesity was present in 48.3% of all COVID-19 hospitalized adult patients
and the Louisiana Department of Health reported a prevalence of 28% in
COVID-19 adult non-survivors [21]
[22]. Based on the existing data, the US
Centers for Disease Control and Prevention (CDC) listed obesity as a risk factor
for severe outcomes of COVID-19, together with diabetes and hypertension [23].
In a retrospective cohort study including data from 795 patients from 45 sites in
the United States, obesity was recognized as a risk factor for disease severity
for pediatric patients hospitalized with COVID-19. Compared to hospitalized
children without obesity, hospitalized children with obesity were more likely to
be diagnosed with multisystem inflammatory syndrome in children (35.7%
vs. 28.1%, p=0.04) and had higher Intensive Care Unit admission
rates (57 vs 44%, p<0.01) with more critical illness (30.3 vs.
18.3%, p<0.01). The adjusted length of stay was also longer in
patients with obesity (2.4 vs. 1.5%, p=0.38) [24]. Another study by Ortiz-Pinto et al.
also showed that the presence of obesity as comorbidity in pediatric patients is
an independent risk factor for COVID-19 infection, but also that long-term
obesity entails a higher risk of infection compared to obesity of shorter
duration. This could be due to increased vulnerability to infection caused by
altered immunological mechanisms in the case of persistent obesity [25].
Several pathophysiological mechanisms have been implicated in the interaction
between obesity and COVID-19 infection or severity. First, it is well documented
that obesity represents a state of chronic inflammation secondary to adipose
tissue hypoxia, which is reflected by increased levels of IL-1, IL-6, and
TNF-α, and may affect the host response to SARS-CoV-2 [26]. In addition, obesity is characterized
by CRP elevation, which is triggered by adipocytic IL-6 and has been correlated
with poor COVID-19 outcomes [27]. It is
also hypothesized that T-cell insulin resistance and exhaustion results in
immunological dysregulation in obesity [26]. The existing immune dysfunction may be exaggerated by attenuated
Mas receptor signaling of angiotensin 1–7 [28]. Furthermore, increased levels of DPP-4
and the consequent hyperinsulinemia may exacerbate COVID-19 risks [29]. Finally, obesity-related
complications, including obesity hypoventilation syndrome and obstructive sleep
apnea, which compromise respiratory function, but also thrombosis risk,
diabetes, and hypertension may also explain COVID-19 severity [30].
Diabetes
During the COVID-19 pandemic, increased number of newly diagnosed type 1 diabetes
mellitus (T1DM) and type 2 diabetes mellitus (T2DM) cases has been reported in
European pediatric populations [31], which
are far beyond the previously expected trajectories [32]. This is consistent with findings in
adult populations [33]. Strikingly,
incident T2DM cases represented for the first time the majority (53%) of
all newly diagnosed pediatric diabetes cases in 2020 and severe DKA in T2DM
cases at presentation were also more during the COVID-19 pandemic [32]. This is of particular concern, knowing
that T2DM has a more aggressive course in adolescents than in adults and that
progression to insulin dependence due to deterioration of β cell
function is rapid [34]. The age at
presentation of T1DM was younger compared to previous years in a study from
Spain [35], whereas no statistical
difference was found in the age at presentation in a study from Greece [36]. Increased severity and frequency of
DKA at diagnosis has also been documented, hypothetically due to delayed
care-seeking or, hypothetically, due to SARS-CoV-2 aggressiveness [36]
[37]. Of interest, one case of multisystem inflammatory syndrome in
children (MIS-C) has been reported in a child with diabetic ketoacidosis [38]. Newly diagnosed DKAs were increased in
44% and new cases of DKA in established T1DM diagnoses were increased in
30% of pediatric endocrine centers in a study from 51 countries
worldwide [39].
Ketoacidosis results from insufficient insulin secretion to meet the glycemic
needs due to autoimmune destruction of β cells in the case of T1DM. In
some of the cases, new-onset insulin-requiring diabetes following COVID-19 was
autoantibody negative, suggesting that COVID-19 may be associated with β
cell destruction [40]. Indeed, it has been
suggested that SARS-CoV-2 may be diabetogenic [41]. SARS-CoV-2 RNA has been detected in pancreatic β cells
of patients with COVID-19 [42], however
there is conflicting evidence regarding the presence of ACE2 receptors in
β cells [43]
[44].
Suggested pathophysiological mechanisms of COVID-19-triggered diabetes include:
i) direct attack of pancreatic β cells by SARS-CoV-2, ii) stress
response to severe COVID-19 infection due to increased cortisol and to the
cytokine storm, resulting in hyperglycemia [45] and iii) the significant insulin resistance seen in patients with
COVID-19 that results in β cell failure [46]. In some of the cases, the risk for diabetes following COVID-19
may be attributed to the COVID-19-related increase in body mass index [47].
Based on the above, awareness of healthcare providers should be raised so that in
persons aged<18 years diabetes is screened for in the presence of
symptoms such as polyuria, polydipsia, increased hunger, weight loss, fatigue,
abdominal pain, nausea and vomiting, following COVID-19 diagnosis.
An aspect that should not to be ignored is that the imposed anti-pandemic
measures have also affected the inpatient care provided in newly diagnosed T1DM.
Diabetes education requires long face-to-face meetings of the patient and the
family with the healthcare team. Preventive measures during the pandemic did not
allow increased exposure to and from the personnel, which usually comprises
multiple members, including diabetes nurses, diabetes educators, doctors,
dietitians, psychologists, social workers [48]. In addition, the COVID-19 protection measures resulted in
restriction in the number of family members that received education to only one,
making diabetes management at home more difficult. This necessitated the
adoption of alternative educational options, such as virtual clinic training or
setting up communication platforms, which require not previously existing
infrastructure and additional time spent by the therapeutic team [49].
Pre-existing diabetes
Data regarding susceptibility of patients with diabetes to infection with
COVID-19 are inconclusive. The majority of pediatric patients with pre-existing
diabetes do not appear to be more susceptible to SARS-CoV-2 infection and
patients below 25 years exhibit a mortality rate that approaches zero according
to a study by Elbarbary et al. [39]
[50]. However, children with T1DM that
contracted SARS-CoV-2 were more likely to develop DKA [51] and were more frequently symptomatic
and with more severe symptoms compared to patients without endocrinopathies or
with other endocrine conditions [39].
Furthermore, the proportion of patients with T1DM who required admission to
Intensive Care Unit was higher (21.2%) compared to patients diagnosed
with other endocrine conditions. Similarly, patients with T1DM needed
bronchodilators and glucocorticoids more frequently (24.8%) than
patients with other endocrine conditions who were tested positive for COVID-19
(e. g., type 2 diabetes: 13.5%, obesity: 15.4%). They
also needed oxygen, non-invasive or invasive ventilation, antibiotics and
antiviral agents more frequently [39].
COVID-19 severity has also been associated with uncontrolled diabetes in adults.
However, contrary to the findings in children, a whole population study showed
increased mortality risk after COVID-19 infection in patients with T1DM and T2DM
[52].
Several pathophysiological mechanisms have been proposed to explain increased
susceptibility of patients with diabetes to more severe COVID-19 infection,
particularly in adults. First, diabetes causes a hyperinsulinemia-induced
reduction in the activity of ADAMTS17, the protease that cleaves ACE2, leading
to increased expression of ACE2 and, thus, facilitating the SARS-CoV-2 cell
entry [53]
[54]. Second, diabetes is associated with factors that exacerbate the
immunodeficiency, such as complement defects, reduced antigen stimulated IL-6,
IL-8, and TNF-α [55], impairment
of T-regulator cells and antigen presenting cells [24]. A third mechanism involves medications
frequently used to treat diabetes in adults, including ACE1 inhibitors,
angiotensin receptor blockers and thiazolidenediones, which may upregulate ACE2
expression. Fourth, co-existing hypertension and obesity may contribute to the
pre-existing chronic inflammation by acting via HIF-1α and toll-like
receptors, leading to impaired immune-mediated clearance of SARS-CoV-2 [24]
[56]. Lastly, dipeptidyl peptidase-4 (DPP-4), a surface glycoprotein
which degrades glucagon like peptide (GLP-1) and also functions as a surface
receptor for coronaviruses [57], is
elevated in diabetes [58]. All the above
mechanisms may predispose patients with diabetes, particularly adults, to
cytokine storms resulting in end organ injury and mortality [59].
Particular reference should be made to the changes caused by COVID-19 in diabetes
management, which is much more challenging and demanding compared to other
endocrine disorders. In the same study by Elbarbary et al., it was found that
insulin adjustments were needed in 56.6% of pediatric endocrine centers
for T1DM and in 26.9% of centers for T2DM [39], whereas for other endocrine conditions
adjustments to therapies were required in a lower proportion of the patients
(obesity: 23.1% of centers, adrenal disorders: 28.8% of centers,
pituitary disorders: 26.6% [39].
Furthermore, more than 20% of the centers worldwide reported shortages
of diabetes supplies, such as glucose test stripes, blood glucose sensors and
insulin due to the COVID-19 related restrictions.
Additional challenges regarding diabetes management due to COVID-19-related
measures include accessibility to medical care. It has been reported that during
the pandemic medical care was mostly delivered face-to-face using appropriate
personal protective equipment and to a lesser extend using telephone and video
consultations [39]. However, due to the
parents’ fear of exposing their children to SARS-CoV-2 and because
priority was given to COVID-19 related health services, routine follow-up visits
were limited [39]. This was mitigated to
some extend by enhancement of remote healthcare for children with diabetes in
some centers during the pandemic, including telehealth visits and remote
transmission of data from insulin pumps, glucose meters or CGM devices via a
cloud-based platform [60]. Nonetheless,
the importance of physical examination including assessment for lipohypertrophy
at insulin injection sites or assessment for neuropathy, pubertal examination,
anthropometric measurements, blood pressure measurement, but also screening for
comorbidities, such as retinopathy, nephropathy, celiac disease, thyroid
disorders and dyslipidemia, cannot be ignored. Also, the increased burden on
health care providers caused by telehealth visits and the cost related to
communication platforms for patients and doctors represent additional barriers
to telemedicine.
Despite the aforementioned treatment challenges during the pandemic, a study from
India showed that glycemic control was adequately maintained in children with
T1DM possibly due to a steady daily routine in the lockdown and when family
support was strong [61].
Hypothalamic-pituitary-thyroid axis
ACE2 receptors are expressed in thyroid tissue and are key components of
physiological processes. In fact, ACE2 receptors are more highly expressed in
thyroid cells than in lung cells [62].
Although most patients with COVID-19 are euthyroid, according to studies in
adults COVID-19 has been implicated in thyroid dysfunction through four
different potential mechanisms: i) direct thyroid tissue damage [63], ii) immune-mediated thyroid damage
through activation of inflammatory factors and cytokines, iii) non-thyroidal
illness syndrome (NTIS) and iv) hypothalamic-pituitary injury that causes
dysfunction of the hypothalamic-pituitary-thyroid action [64].
Non-thyroidal illness syndrome (NTIS) and thyroiditis have been reported in
3.6% of adult patients with COVID-19, particularly in patients with an
increased viral load of inflammatory markers [65]. In a study by Muller et al., adult patients with COVID-19
requiring high intensity care presented with thyrotoxicosis and suppressed TSH
levels, either with or without increased free thyroxine levels, following
subacute thyroiditis [66]. Interestingly
though, TSH concentrations were not as suppressed, and free thyroxine
concentrations were not as elevated as in the classic subacute thyroiditis. In
addition, affected patients did not complain of neck pain, nor did they exhibit
leukocytosis. In contrast, they exhibited lymphopenia, which is well described
in COVID-19 [67]. NTIS has also been
recognized in children with MIS-C and is considered as an energy-preserving
adaptive mechanism during severe illness and hypercatabolic state [68]. Therefore, in patients with severe
COVID-19 routine assessment of thyroid status is recommended.
NTIS is caused by physiological stress and is characterized initially by a
reduction in total T3 and free T3 without a concomitant rise in TSH. Persistent
illness results in reductions in TSH, free T4 and free T3 due to a reduction in
hypothalamic thyrotropin-releasing hormone [69].
Interestingly, the available data suggest that after acutely altered thyroid
function during COVID-19, thyroid function tests return to baseline after
recovery and by 3 to 6 months after the infection [70].
Pre-existing thyroid disorders
Regarding patients with pre-existing thyroid dysfunction, the majority of data
comes from adult studies. Thus far, there is no evidence to support that
patients with thyroid nodules, autoimmune thyroid disease or cancer are more
susceptible to contracting COVID-19. In addition, hypothyroidism does not appear
to increase the risk for more severe disease in adults with COVID-19 [71]. Among pediatric patients, it remains
unclear whether pre-existing thyroid disease increases susceptibility to
COVID-19 infection, however, data from a retrospective cohort study from the
United States in children suggest that hypothyroidism is an independent risk
factor for disease severity [72].
Patients with hyperthyroidism are also not at increased risk of COVID-19
infection. Only some subsets of hyperthyroid patients, such as patients with
thyroid ophthalmopathy treated with glucocorticoids and immunosuppressive
therapy are at increased risk for more severe disease once infected [73]. Also, COVID-19 may affect patients
with hyperthyroidism in two additional situations; First, it may precipitate a
thyroid storm particularly in poorly controlled patients with hyperthyroidism
through activation of an excessive immune response. Therefore, it is recommended
that patients with hyperthyroidism continue to receive their medications to
avoid complications [74]. Second, patients
with Graves disease treated with antithyroid medications are at increased risk
of neutropenia/agranulocytosis and secondary infections [75]. Knowing that almost half of COVID-19
non-survivors had a secondary infection [76], this is of clinical relevance. Furthermore, symptoms of
agranulocytosis, flu-like symptoms, may be difficult to differentiate from those
caused by COVID-19. Therefore, it is recommended that in such cases antithyroid
drugs are immediately discontinued and a full blood count is obtained to exclude
neutropenia [71].
Hypothalamic-pituitary-adrenal axis
Glucocorticoids are known to stimulate the immune response against foreign
antigens during the initial phase of a viral infection, whereas during the
advanced phase of viral infection, glucocorticoids may attenuate the
hypothalamic-pituitary-adrenal axis, thus cause glucocorticoid insufficiency
[77].
Also, critical illness in general is known to cause corticosteroid insufficiency
due to suppression of the hypothalamic-pituitary-adrenal axis secondary to
physiological stress [78]. In a study by
Gonen et al., 8.2% of adult patients with COVID-19 developed secondary
adrenal insufficiency, which in some of the cases was transient and had resolved
six months after the COVID-19 onset [79].
However, although there are some indications of adrenal insufficiency caused by
COVID-19, this has not been confirmed and the majority of patients with COVID-19
seem to preserve their adrenal function during the first 48 hours after
hospital admission. On the contrary, according to a study by Clarke et al.,
increased serum cortisol concentrations have been observed during the first 2
days of hospital admission in adult patients with COVID-19 [80], which suggests activation of the
cortisol axis in acute illness and has been associated with increased mortality
[81].
Interestingly, although symptoms reported by patients with long COVID are similar
to those caused by adrenal insufficiency, for example, fatigue, postural
hypotension and cognitive impairment, there is no evidence to support an
association between the two [82].
Pre-existing adrenal disorders
Patients with existing primary adrenal insufficiency, including congenital
adrenal hyperplasia, are slightly more susceptible to infections, as primary
adrenal insufficiency is associated with diminished natural immunity function
through defects in the neutrophil and natural killer action [83]. However, there is insufficient data to
support increased COVID-19 specific infection risk. On the other hand, it is
well established that increased susceptibility to infections can be due to
insufficient increase in the hydrocortisone dose at the beginning of an
infection and that adrenal insufficiency is potentially associated with
increased mortality due to adrenal crisis [84]. Therefore, recommendations suggest that asymptomatic children
should remain on their regular doses, but symptomatic children should
immediately increase the hydrocortisone doses and add an extra doubled dose
[39]. Also, adhering to protective
measures and sick-day rules is highly recommended [85]
[86].
Similarly, in the case of Cushing syndrome, the importance of adhering to
protective measures, reinforcement of sick-day rules, treatment of comorbidities
and titration of pharmacotherapy doses based on clinical characteristics, is
emphasized [87].
Hypothalamic-pituitary-gonadal axis
Various studies in adult male patients with COVID-19 have shown a reduction in
total or calculated free testosterone levels [88]. The majority of men with low calculated free testosterone levels
also had low or normal serum LH values, suggesting hypogonadism due to
hypothalamic-pituitary dysfunction, which is known for physiological stressors
[89]. Interestingly, lower median
testosterone levels were observed in men with severe COVID-19 and testosterone
levels were inversely related to cytokines, that is, IL-6, and C-reactive
protein (CRP), which points towards immune-mediated hypogonadism [90]. The documented reduction in
testosterone levels during the acute phase of the COVID-19 infection resolves
spontaneously in the majority of the cases after recovery from COVID-19 [91].
Regarding the effects of COVID-19 on ovarian function or the
hypothalamic-pituitary-gonadal axis in females, data are scant and inconclusive.
Changes to women’s menstrual cycle, including irregular periods, heavy
periods and postmenopausal bleeding, have been reported [92], but it is not clear whether these
changes are related specifically to COVID-19 or to psychological stress and
weight gain. Precocious puberty, rapidly progressing puberty and precocious
menarche have also been observed in pediatric endocrinology centers [93]
[94]
[95]
[96]. A direct effect of SARS-Cov-2 on the
central nervous system could be hypothesized, through transportation through the
blood-brain barrier and neural pathway activation, or an indirect effect through
the release of pro-inflammatory cytokines [94]. Further research is warranted in order to confirm these
observations for the adult population, but also for adolescents.
Anterior pituitary disorders
No pituitary disorders have been reported so far following COVID-19 infection in
children, however, one case of pituitary apoplexy has been reported in a
previously healthy 35-year old male secondary to COVID-19 infection [97]. This care report raises concerns for
potentially missed diagnoses of CNS COVID-19 involvement. However, this
potentially lethal complication is more likely an uncommon presentation of
COVID-19.
Pre-existing pituitary disorders
Children with hypopituitarism are not at increased risk for COVID-19 infection.
Those with secondary adrenal insufficiency are slightly more susceptible to
infections, as in primary adrenal insufficiency, and the same recommendations
apply [98].
Diabetes insipidus
Management of diabetes insipidus during the pandemic posed a challenge due to the
fear of overtreatment that can lead to retention of excess free water and,
consequently, hyponatremia. In the scenario of reduced availability of
electrolyte testing due to the pandemic-related restrictions, daily bodyweight
measurements, drinking to thirst and never ignoring clinical symptoms of
hyponatremia, were recommended as a means of mitigating the risk. In the case of
severe COVID-19 pneumonia, hyponatremia may develop in the context of
inappropriate antidiuretic hormone secretion, particularly in adipsic patients
[99]. Systematic biochemical
assessment of sodium levels and appropriate fluid administration are of vital
importance during inpatient care, optimally guided by an Endocrinologist [100].
Parathyroid disorders
Viral infections are known to precipitate hypocalcemia [101]. The association between hypocalcemia
and COVID-19 infection has also been reported [102], and it seems that hypocalcemia is a risk factor for severe
disease and admission to the Intensive Care Unit [103]
[104]. Suggested mechanisms of COVID-19 induced hypocalcemia include
increased levels of unbound and unsaturated fatty acids [105] in patients with severe COVID-19
infection, which can trigger a cytokine storm [106], but also bind calcium [107]. However, it is not clear if this is an association only or
there is a causal relationship between the two. Patients with severe infection
are more likely to present with electrolyte derangement, including hypocalcemia,
and have poorer outcomes.
With regard to the potential link between COVID-19 and hypoparathyroidism,
evidence is lacking. There are only few case reports of hypoparathyroidism
secondary to COVID-19 infection in adult patients [108]
[109].
Patients with pre-existing parathyroid disorders
For children with pre-existing hypoparathyroidism, it is recommended that they
comply with vitamin D and calcium supplementation and that they maintain serum
calcium levels in the low normal range. It is also important that patients are
frequently re-educated so that symptoms of hypocalcemia are recognized, and that
emergency preparedness is ensured.
Primary hyperparathyroidism is rare in children. Recommendations include
education on the symptoms of hypercalcemia and the importance of adequate
hydration.
Metabolic bone disease
In a study by Alshukairi et al., children with osteogenesis imperfecta and
COVID-19 exhibited a mild course of the disease and recovered without
complications [110]. Children with
metabolic bone disease or a skeletal dysplasia that affect chest wall structure
and respiratory sufficiency may be at increased risk of COVID-19 complications
[111]. In addition, transient benign
hyperphosphatasemia (THI) has been reported in a 16-month-old patient in
association with COVID-19 [112].
Therefore, THI should be considered as a possible diagnosis if alkaline
phosphatase (ALP) is elevated in the absence of bone, liver or kidney disease
[113].
Hyperinsulinemic hypoglycemia
The side effects of the medications used to treat hyperinsulinemic hypoglycemia
should be taken into consideration during contamination with COVID-19.
Specifically, diazoxide is known to cause water retention and pulmonary
hypertension, and somatostatin analogues cause cardiac arrhythmias and cardiac
conduction disorders, which may affect the course of the illness with COVID-19
[39]. Also, close monitoring of
glucose concentrations and adequate hydration are essential.
Endocrine conditions and mental health during the COVID-19 pandemic
Mental health issues have been exacerbated during the pandemic throughout society
and in patients with endocrine conditions [114]. Due to children’s not completed development of the
central nervous system, including the hypothalamus-pituitary-adrenal axis,
children exhibit increased susceptibility. Anxiety, depression, sleep disorders,
eating disorders and suicidal attempts were commonly reported problems among
children and adolescents with endocrine problems and COVID-19 infection. [39]. Based on the above, routine medical
care provided should be focused on providing psychosocial support to children
and their families, particularly those suffering from chronic endocrine
disorders.
Discussion
The impact of COVID-19 beyond the respiratory system has become apparent as our
knowledge on this novel disease is increasing. Among others, the endocrine system
is
particularly vulnerable to perturbation from the COVID-19 infection and children are
not exempt. However, in the majority of cases, pediatric endocrine disorders are not
considered a poor prognostic factor for COVID-19 infection and most children and
adolescents with well-managed and regulated endocrine disorders do not appear to be
at increased risk of infection or severe infection from COVID-19 [39]. Importantly, obesity increases the
vulnerability of the pediatric population to COVID-19 and severe COVID-19 and
pediatric patients with T1DM or T2DM are also more likely to suffer from COVID-19
and to experience moderate to severe symptoms, particularly in the presence of
comorbidities [115]
[116]. Long-term studies are, however, needed to
further ascertain the potential association between COVID-19 and increased diabetes
risk in children and adolescents.
Of note, children and adolescents with endocrine conditions who were admitted to the
Intensive Care Unit often had comorbidities [117]. Comorbidities are less frequently seen in children and adolescents
compared to adults, which probably accounts for the reduced vulnerability of
children and adolescents to COVID-19. Taking, though, into consideration the rise
in
obesity and T2DM rates in children and adolescents, an increasing number of children
and adolescents at risk could become apparent in the future.
One of the most important key messages of this literature review is the disruption
of
children’s everyday routine during the COVID-19 pandemic that has resulted
in a significant psychological burden, but also in a tremendous aggravation of
childhood obesity, due to the unhealthy dietary choices that have prevailed and the
COVID-19-induced lifestyle modifications [118]. The importance of the implementation of preventive or counterregulatory
measures from policy makers and healthcare providers, including healthy nutritional
behaviors, is highlighted.
Another important lesson from the existing literature is that the fear of becoming
infected may have hindered families from seeking medical help. This appears to have
resulted in delayed new diagnoses of many pediatric diseases [119], including endocrine disorders, and,
particularly, DKA cases [36]
[37]. Thus, a secure non-COVID-19 path through
pediatric emergency department is essential so that delayed seeking of medical care
and the associated complications are avoided. Also, although face-to-face visits are
the commonest method of consultation, provision of efficient telemedicine methods
(video calls, emails, text messaging) and remote consultations is also of
significance. The experience so far shows that telemedicine will probably be
integrated into clinical practice after the COVID-19 pandemic, as it was proven an
essential tool for delivering care during the pandemic, despite the compromises
involved [120]
[121].
Importantly, it should be emphasized that due to redistribution of health care
resources and due to health system capacities being directed to COVID-19 patients,
patients with chronic afflictions, including endocrinopathies, were the most likely
to lack specialized care. This is particularly true for patients with diabetes,
since diabetes is more complex to treat than other endocrine conditions in children
and is associated with increased risk of morbidity and metabolic complications, such
as DKA.
In addition, in some parts of the world, access to endocrine and diabetes care
medications and supplies was also restricted during the pandemic. Therefore, the
American Diabetes Association (ADA) recommends adequate stores of simple
carbohydrates, insulin, glucagon kits, ketone strips [122]. Healthy dietary behaviors and
150 minutes of weekly exercise are also encouraged.
Furthermore, the majority of children with endocrine disorders are not at increased
risk for contamination or severe presentation of COVID-19, therefore adhering to the
appropriate “sick day management rules”, maintaining adequate supply
of medications and supplies, being in close contact with the therapeutic team and
seeking medical help without delay when needed, are the cornerstone of a safe and
optimal approach [123]. Regarding healthcare
providers, remaining up to date with emerging knowledge and literature, re-educating
patients on all routine clinical visits with emphasis on emergency precautions, and
highlighting potential risks taking into consideration mental and physical health
parameters, is important to ensure quality of care. When face-to-face contact is not
feasible, alternative communication methods, such as telemedicine care, should be
adopted, as well as mailing of prescriptions instead of in person pickup, so that
endocrine care remains uninterrupted. Also, although no deaths were observed for any
endocrine condition during the pandemic, the potentially negative effects of the
interaction between COVID-19 and endocrine conditions underscore the importance of
adopting protective measures, including vaccination for eligible children and
adolescents, against COVID-19 infection.
