Hi HOPE The congenital Hyperinsulinism

Spring 2013
The Congenital
Hyperinsulinism
Center
hi HOPE
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meet our TEAM
Focus on Medically Managed Patients
Endocrinology
Of the total population of children who are diagnosed with congenital hyperinsulinism (HI),
approximately half have diffuse disease, which means the insulin-spewing beta cells
are distributed throughout their pancreas. A small percentage of the children who have
diffuse HI and are unresponsive to diazoxide can be managed medically and avoid surgery
to remove most of their pancreas.
Diva D. De León-Crutchlow, M.D.
Director, Congenital Hyperinsulinism Center
Andrea Kelly, M.D.
David Robert Langdon, M.D.
Andrew Palladino, M.D.
Charles A. Stanley, M.D., Founder,
Congenital Hyperinsulinism Center
Nursing Staff
Linda Boyajian, M.S.N., C.R.N.P.
Teresa Dansbury, B.S.N., R.N.
Enyo Dzata, M.S.N., C.R.N.P.
Amanda Lee, M.S.N., C.R.N.P.
SURGERY
Diffuse Disease Treated Without Surgery
From the looks of Naomi* now, a bright kindergartner who knows her ABCs and
is teaching herself to read, you’d never know she went for nine months before her
congenital hyperinsulinism (HI) was properly treated.
“We are so grateful that she never had any seizures or brain damage,” her mother, Esther*,
says. “She never had any symptoms, other than low blood sugars.”
Low as in really low, from Naomi’s second day of life.
RADIOLOGY
Esther had a normal pregnancy and delivery in her
local Brooklyn, N.Y., hospital and thought all was
well until a doctor rushed in the next morning and
said Naomi had been moved to the Newborn Intensive
Care Unit because of hypoglycemia. Doctors began to
give her dextrose intravenously, thinking the lows would
pass. They upped the amount, but still Naomi was
hypoglycemic. It wasn’t until a week had passed that
she was started on diazoxide, the frontline medication
for HI. It seemed to help, at least a little.
Diego Jaramillo, M.D., M.P.H.
Chief, Department of Radiology,
Radiologist-in-chief
Lisa J. States, M.D.
Hongming Zhuang, M.D., Ph.D.
Naomi at 6 months
After five weeks in the NICU, Naomi came home.
Esther and her husband had been taught how to pump
her full of dextrose and were given strict instructions: “Feed her every three hours,
on the dot,” Esther says. “She grew a lot of facial hair, and she was fat, really fat,
because we were always feeding her.”
PATHOLOGY
A stomach virus at 7 months landed Naomi back in the local hospital, where doctors
placed a feeding tube through her nose to better keep the dextrose flowing. After
Naomi spent two months in and out of the hospital, the local endocrinologist admitted
he couldn’t help her and recommended Esther bring Naomi to CHOP. “They were
at a loss what to do,” Esther says. “One night, her low sugars dropped to 18.”
N. Scott Adzick, M.D., M.M.M.
Chief of General, Thoracic and Fetal
Surgery, Surgeon-in-chief
PEDIATRIC ANESTHESIOLOGY
Ari Weintraub, M.D.
Pierre A. Russo, M.D.
Chief, Anatomic Pathology
Eduardo Ruchelli, M.D.
NEONATOLOGY
Jacquelyn Evans, M.D.
Director, N/IICU
Rebecca A. Simmons, M.D.
DEVELOPMENT
Mary Cooney
Contact us at
[email protected]
Once under the care of Charles Stanley, M.D., in the Congenital Hyperinsulinism
Center, Naomi was diagnosed with diffuse disease and started on a regimen of twicedaily shots of octreotide with continuous dextrose via a feeding tube overnight.
Most children with the genetic mutation Naomi has, the common Ashkenazi Jewish
ABCC8 HI mutation, require a 95 to 98 percent pancreatectomy. However, Naomi
was stable and ready to go home in two weeks. The nasogastric tube was replaced
with a gastrostomy tube a few months later, and the combined octreotide-dextrose
continued on next page
Continued from front Diffuse Disease Treated Without Surgery
treatment has controlled her HI ever since. At CHOP, only
a small percentage of patients with recessive mutations in
ABCC8 have been able to be treated without surgery.
“She’s totally normal, rambunctious, lively,” says Esther.
“The only help she gets is from a health paraprofessional, who
checks her sugar and gives her something to eat if it’s low.”
And that’s only as a precaution. Naomi has been checking
her own sugar since she was 3, smart girl that she is.
*Names were changed at the family’s request.
Gastrostomy Tube Tips and Reminders
By Amanda Lee, M.S.N., C.R.N.P.
For many children with HI, having a gastrostomy tube
means having a lifeline. Whether the tube is used for
occasional boluses of dextrose when a blood sugar is low or
for continuous administration of dextrose water overnight,
the easy access it provides is essential. But the gastrostomy
tube (GT) is not without its challenges. From securing it
early on when a baby with HI begins to roll over in his crib,
to finding a backpack for carrying the pump around when
the child is older, each developmental stage can bring a new
challenge. Here are a few pointers and reminders for those
with a GT:
1.Even if you live far away from CHOP, it is a good idea to
be seen intermittently by a pediatric surgeon and his or
her team. They can help with tube sizing, tube removal
and tube replacement, if it ever comes out. Your pediatrician
can recommend a local pediatric surgeon if you do not
already have one.
2.Skin care is easy. The stoma (opening) site and surrounding
area only need to be washed with mild soap and water.
Anything more than this can cause skin breakdown.
Some yellow-brown drainage at the site is normal.
Please contact your surgical care provider to check out
any leakage at the site.
3.Some granulation tissue may develop at the site. It is
typically dark pink or red, and it is the body’s natural
response to the tube. If your child has a lot of this tissue,
there can be leakage and skin irritation. Please contact your
surgical care team for treatment of painful granulation tissue.
4.Do you remember what to do if the GT comes out? No
matter how long the GT has been in place, the opening
can close very quickly. If you have a Foley catheter (and
you should), place the end of it into the stoma about 1 to
2 inches and tape in place. Then call your child’s doctor
right away.
5.Always remember that your child’s tube does not need to
affect normal activities. Your child can bathe, play, swim
and sleep; it just might require some creativity! Please
contact us with any questions or concerns, or if you need
help troubleshooting. We’re available at 215-590-7682 or
[email protected]
Pilot Study
Investigational Drug Shows
Promise for Diffuse HI Patients
Children’s Hospital, building on a pilot study in adolescents
and adults, has found that an investigational drug,
exendin-(9-39), could point to the first potential
medical treatment for children with the severest type
of congenital hyperinsulinism. These children currently
face a near-total pancreatectomy. About half of HI
patients, who have diffuse disease and are unresponsive
to diazoxide, could potentially benefit.
Under the leadership of Diva D. De León-Crutchlow,
M.D., director of CHOP’s Congenital Hyperinsulinism
Center, study results showed that exendin-(9-39)
successfully increased fasting blood glucose in nine
patients, aged 15 to 47 years old, who had hyperinsulinism
caused by mutations in potassium channels. The study
provides proof of concept that will allow for larger
studies in the future, and hopefully FDA approval of
the medication. The center is preparing an expanded
clinical study for 2014.
Exendin-(9-39) blocks the action of a hormone, glucagonlike peptide-1 (GLP-1), in beta cells. The GLP-1
receptor is currently the target of drugs that treat
diabetes, using the opposite effect from that investigated
in this HI study.
None of the study subjects were being treated for
HI at the time of the study, but all were at risk of
hypoglycemia during periods of fasting. In all nine,
the drug controlled blood glucose levels during fasting.
Exendin-(9-39) also controlled insulin secretion in cell
studies of beta cells taken from newborns with HI.
Also, De León-Crutchlow and HI Center researcher
Katherine Lord, M.D., are studying how many children
with surgically treated hyperinsulinism develop diabetes
and developmental or behavioral problems. From this
study, researchers hope to better understand the long-term
risks associated with hyperinsulinism and its treatments
and provide better guidance to families.
The center is enrolling subjects who had a
pancreatectomy for HI between 1960 and 2008.
Subjects will be asked to do an interview with
researchers about their blood sugars and medical history
and also to complete two developmental/behavioral
screens. The interview can be done over the telephone,
and the screens will be mailed to subjects. Some subjects
can also undergo free diabetes screening and formal
neurodevelopmental testing, if they are willing and meet
certain criteria. Please call Lord at 267-425-2125 or
email her at [email protected]
A Grandfather’s Love Will Help
Many HI Patients
There is no doubt that Oliver Fallon is one of the lucky ones —
if you can call getting a rare disease like congenital hyperinsulinism
(HI) lucky.
Oliver didn’t have any signs of low blood sugar until he was weaned
from breastfeeding at 6 months old. When he had a seizure at
home, his parents rushed him to Mount Sinai Hospital in New
York City, where the emergency room doctors tested his blood
immediately and found the hypoglycemia. Physicians there were
able to diagnose him with HI within a week. Oliver was put on
diazoxide, and it worked. With the medication and some diet
changes, his HI was well controlled.
Oliver Fallon with his grandfather, Clifford Goldsmith
To top off his good luck story, Oliver has outgrown the disease
and is no longer on medication, putting him among the
approximately 5 percent of medically managed HI patients
able to halt medication. Oliver, now 9, is a typical kid; he plays
baseball and the piano.
about Dr. (Charles) Stanley and suggested we talk to him.”
When Oliver came to CHOP in 2004 for protein and fasting
tests, Goldsmith and his wife, Katherine, came along.
But his grandfather, Clifford Goldsmith, knows there are other
children whose experience with HI is much more difficult. To
help them and future patients, Goldsmith has made generous
donations to the Congenital Hyperinsulinism Center at The
Children’s Hospital of Philadelphia to fund HI research.
The first set of tests showed that Oliver could indeed eat protein
without making his blood sugar plummet. That allowed him a
more balanced diet. And a year ago, Oliver came back to CHOP
for more tests that showed he didn’t need diazoxide anymore.
In between, Goldsmith had met with Charles Stanley, M.D.,
who founded the HI Center, and Diva D. De León-Crutchlow,
M.D., the center’s director. His favorable impression of the HI
Center grew, and he signed on to support its research. The HI
lab is now named Fallon-Goldsmith Hyperinsulinism Laboratory
in honor of his gift.
“I know it’s hard to find funding for rare diseases,” says Goldsmith,
a trustee at Mount Sinai who has funded a center for multiple
sclerosis there in memory of his daughter Corrine, who had MS.
Why CHOP? Even though Oliver was doing well on the
medication eight years ago, his doctors had put him on a lowprotein diet. Oliver’s mother and Goldsmith’s daughter, Alex
Fallon, says her father was “Googling around and found out
“I was so impressed by everything
that went on at CHOP,” Goldsmith says.
“They did so much to help Oliver.”
“I was so impressed by everything that went on at CHOP,”
Goldsmith says. “They did so much to help Oliver.”
Every Monday, Oliver goes to his grandparents’ apartment in
New York City for his weekly piano lesson. Afterward, he stays
for dinner and listens to his grandfather talk about his childhood
in Germany. Goldsmith left Germany when he was 16, went to
college in England, came to the United States when he was 20
and, when World War II broke out, volunteered for service in
the U.S. Army. He was captured by the Germans and spent five
months as a prisoner of war in Germany.
It’s compelling stuff for a 9-year-old with a penchant for history.
But Oliver has fought his own battle and, remarkably, he’s won.
And now his grandfather is arming CHOP’s HI Center to
continue the fight to find better treatments and hopefully, one
day, a cure for congenital hyperinsulinism.
De León-Crutchlow Assumes Leadership of Center
Charles Stanley, M.D., who has treated patients with congenital hyperinsulinism before
the disease was even routinely called that, has moved into the director emeritus position
at CHOP’s Congenital Hyperinsulinism Center, which he formally founded in 1998.
Dr. Stanley, a world-renowned expert on disorders of insulin regulation in children,
will continue to conduct research at the center.
Charles Stanley, M.D. Diva D. De LeónCrutchlow, M.D.
Diva D. De León-Crutchlow, M.D., who has been at CHOP since 1999, is now
director of the center. Her research interests focus on the interaction between glucagonlike peptide-1 and the insulin-producing pancreatic beta cells in the pathogenesis of
congenital hyperinsulinism and other hypoglycemic disorders.
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We’re proud to announce that the Parents magazine 10 Best Children’s
Hospital survey ranked The Children’s Hospital of Philadelphia No. 1
overall nationwide. See the survey in the March 2013 issue as well as
online at www.parents.com.
The Division of Endocrinology at CHOP is ranked No. 1 among all
pediatric hospitals in U.S.News & World Report’s Best Children’s Hospitals
survey for 2012-13. CHOP also tied for the No. 1 ranking overall on
U.S.News & World Report’s Honor Roll of Best Children’s Hospitals.
(Parents does not rank Endocrinology.)
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[email protected]
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