Dr. Rob Steele (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast, and claim your CME through the little button that says Claim CME.

Today, we are joined by Dr. Ryan McDonough to discuss common cases of diabetes. Dr. McDonough received his undergraduate degree from Creighton University and his Doctor of Osteopathic Medicine degree from Des Moines University in 2010. Following med school, he completed a General Pediatric Residency and Pediatric Endocrinology and Diabetes Fellowship here at Children's Mercy Kansas City, and then joined the faculty in the Division of Pediatric Endocrinology at Children's Mercy in 2016. He serves as the Co-Medical Director of the Children's Mercy Diabetes Center, and as the Chief Medical Informatics Officer and Senior Medical Director for Health Informatics. In fact, he is triple boarded in General Peds, Pediatric Endocrinology and Diabetes, and Clinical Informatics. My goodness! I mean, that is a bar that is set way too high for me. I got to tell you, Ryan. And he was recently promoted to Professor of Pediatrics at the University of Missouri, Kansas City School of Medicine. Congratulations on that. Thank you for joining us today, Dr. McDonough.

Dr. Ryan McDonough: Yeah. My pleasure. Thanks. It's always funny to hear someone read your bio and try not to blush, I guess.

Host: Well, hey, you earned it. That's very impressive. But I'll tell you what's more impressive is that you hail from the Halloween capital of the world in Anoka, Minnesota. Is that true?

Dr. Ryan McDonough: That is true. Yes. It's self-proclaimed, and it was because they had the first Halloween parade that was ever reported. A matter of fact, on my lanyard here, you see a little ghost, a little homage to home.

Host: Yeah. Very good. Well, for our listeners around the country, we are on video. You can't see video, but there is a ghost on the lanyard. I can let you know that for sure. Well, I got to ask, is there a lot of pressure for you and your family to really do up Halloween?

Dr. Ryan McDonough: We have to. There has to be a family commitment. This year, we're a vampire, a pirate, and our four-year-old kept referring to both as vampirates. So, he was a vampirate basically.

Host: Awesome. A little mashup. I like that. That's awesome. Well, this is a really great segue. So, you are self-proclaimed king of Halloween, at least in your neighborhood, which is interesting, giving away candy for a diabetes specialist. So, I'm sure that's not lost on anyone.

Let's go ahead and jump right on into it. How about it? We're going to focus really on type 1 diabetes. I think that we could probably spend a whole 'nother podcast on type 2 diabetes. And maybe we will, we'll pull you in for a second one. But let's focus in on type 1. And so, what age are you generally seeing that first onset of diabetes in general?

Dr. Ryan McDonough: Type 1 has got a bimodal incidence, so we tend to see it at really two distinct times. Right around that two to four year-old range, so in that kind of preschool, early pre-K. And then, right again during puberty, so that 10 to 14 year-old range. We tend to see the biggest incidents come with new diagnoses.

Host: There's been theories about what tips you over, what causes type 1 diabetes. Do we have any real good theories as to those typical things that we think might actually be causing diabetes?

Dr. Ryan McDonough: We've really redefined the way that we think about type 1 diabetes because historically we always said, "Okay. You'd come in, you're in diabetic ketoacidosis, you've got florid overt hyperglycemia, and you've got type 1 diabetes now." Well, but did you have diabetes yesterday? Yes. And did you have it a week ago? A month ago? A long time ago? We actually know through epidemiologic studies that the autoantibodies that cause type 1 diabetes can be present for up to a decade or more before someone actually becomes insulin-requiring. So, there's a genetic component, there's a genetic risk. We think there's environmental triggers that then set off that autoimmunity, but there haven't been one identified cause yet. There's a lot of theory around Coxsackie B virus, especially during COVID, we were trying to blame everything on COVID, but we did see a little bit more incidence of T1D during that time.

So, there's genetic risk, environmental or local trigger, and then the autoimmunity happens, so much so that we've actually now said, once you have two autoantibodies, you have type 1 diabetes. You've got stage 1, normal glycemic diabetes. Then, stage 2 inherently comes next, which that is when you're starting to have some dysglycemia. And then, stage 3 is what we have always historically just known as type 1.

Host: Great. So, those are the stages that we see as we're diagnosing type 1 diabetes. So now you've diagnosed that patient. There's all kinds of education, of course, that has to occur, as well as a large number of treatment options that weren't even present even as of 10, 20 years ago. Can you talk about what those treatment options are, and maybe as a function of age of the child? Because I know as they get older and more sophisticated, that opens up additional options.

Dr. Ryan McDonough: Yeah. And I think you hit the nail right on the head about the education being such a critical component of the new diagnosis. We're asking people in a moment of crisis to start learning about a potentially lethal disease, a potentially life-limiting disease, and a potentially life-threatening medication to treat that disease in a very small period of time. We ask families to absorb this information very quickly. We've modeled our educational curriculum over three different classes over the course of several weeks to let people digest the information, go home, start living with the disease a little bit more, and then come back with more questions and build on that knowledge.

But just to complicate things even more, your question about technology, yeah, we have excellent technology that supports this disease now, but they are complex devices. They are not easy to learn. They take time and they can be potentially really intimidating for families. We kind of have two separate categories of the technology. So, there's the first, which is continuous glucose monitoring, which has really revolutionized the way that we view and monitor diabetes data for kids. If you think about historically, finger sticks, you do four or five, six times a day. And I would have been thrilled with that many times a day. Because there's a lot of teenagers out there who were only checking their--

Host: Eh, once other day, we're good.

Dr. Ryan McDonough: Yeah, exactly. So if I got four a day, I was pretty stoked. But then, we talked about these continuous glucose monitors, which are nearly continuously reading interstitial glucose and reporting a value every one to five minutes. So, we're talking 288 to 1440 values a day. That is remarkably different than the finger sticks. The additional piece of that is it gives you context. It doesn't just tell you the number. When you poke someone's finger, you get a blood sugar of 120. Okay, great. That sounds perfect. But what if your blood sugar is 120 and now you have directionality as well, predictive directionality? It says your blood sugar is tanking, you're dropping really fast, versus your blood sugar is skyrocketing. So, those three scenarios, the 120 that is stable, 120 going up really fast or two arrows implying going down, going really fast, you're going to treat that 120 very differently. So, it adds a lot of context, but it also adds a lot of stress, because everyone here gets notifications on their phone. Can you imagine getting one every five minutes that you have to do or process? That's a lot.

And then, the other category of treatment modalities is the technologies that are insulin pumps. Insulin pumps are great. They are wonderful technology, and now they can actually connect with the continuous glucose monitor to self-adjust some of the insulin delivery that we see. But they can malfunction just like any other technology, and they are still not perfect. People will refer to these sometimes as artificial pancreas. You still have a lot of user interface.

And to your question about age, the technologies are great at any age, but the amount of intervention that is required of the child and required of the parent varies very dramatically as we go through those adolescent stages in particular. But they're wonderful resources. They have revolutionized the way that we take care of diabetes and have improved the outcomes that we see, but not without work. And I think that's the important part to hear, is that there is still a lot of work that goes into these, even when you are on these advanced technologies.

Host: Yeah. That is fantastic insight. And that's all undergirded. What I hear you saying, Dr. McDonough, is that your diabetes educator is like gold.

Dr. Ryan McDonough: Absolutely. They play such a pivotal role in our education, in our ongoing maintenance and management of our patients. They are BFFs with some of our patients. So, they play a pivotal role.

Host: Just the evolution of intervening with that child at first diagnosis, it used to be that every child got admitted to the hospital for several days to get educated and all that. For the child that isn't in florid DKA, where are we in 2024 with regard to how we intervene and begin to treat that child that's newly diagnosed?

Dr. Ryan McDonough: it harkens back to the concept that we were trying to get people to drink from a fire hose at diagnosis in a crisis moment. And we realized it took us all some time, right? This was not just Children's Mercy. This was across the U.S. and global population of people diagnosed that maybe that wasn't the best approach to education. And now, we at Children's Mercy do primarily ambulatory education in much smaller chunks that give people the time to process. So, we do primarily outpatient education for kids who are not in DKA. Obviously, DKA gets admitted.

Our goal is to try and minimize some of the anxiety surrounding the disease. Because you get them into the hospital, you're sick, right? When we were admitting kids with new diagnoses, we don't want people with diabetes to think they're sick just because they have diabetes. So, this ambulatory approach, which we call LAND or Learning About New-Onset Diabetes, is outpatient curriculum that really helps demystify some of the anxiety and takes away some of that burden of that new-onset education for families.

Host: Yeah. Great. You know, a number of our listeners are primary care pediatricians. And there's obviously an interplay between the endocrinologist and that team, as well as the their primary care pediatrician and their team. Can you talk a little bit about how that coordination is generally done, recognizing that there are going to be primary care physicians that are in relatively rural areas that don't have an endocrinologist in town, and then others, when we're in a larger city like Kansas City, where we've got folks like yourself? So, how do you coordinate that with the primary care physicians?

Dr. Ryan McDonough: I think we're really lucky. One of the maybe good things that came out of COVID was we actually have done a lot better job of engaging in telehealth and engaging in that remote ability to monitor our patients and to communicate and connect with our community partners. It is a partnership. It has to be. At the end of the day, I don't expect a primary care physician to prescribe insulin, make adjustments to an insulin pump, do the downloading of those technologies. That's my job. But we want to do it as a partnership because those patients still have ongoing needs for primary care. I can't tell you the number of times that I get asked to fill out sports physicals as an endocrinologist, because they see me quarterly. So, they just assume that I'm their primary care doctor. So, it's also my responsibility to make sure they know they still have a primary care doctor, and that those ill-visits, those preventative maintenance, preventative healthcare visits, those are your place. And we don't want to step on your toes. So, it has to be a partnership and collaborative. Regardless if you're three hours away or three minutes away, we want to be in lockstep with you.

Host: And then, for the parent that now has gotten more comfortable, their child's been diagnosed, they're getting better at understanding the disease and the process and how to intervene and when to call and when not to call. And then the question comes, well, what about my other children? Do you have recommendations with regard to how siblings, given that there is potentially a genetic component to type 1 diabetes, what's the recommendation at this point?

Dr. Ryan McDonough: One of the first things that I walk into a room and tell somebody their kid has type 1 diabetes that they tell me or they'll say to me is, but we don't have a family history of it. And 80-90% of the time, that's the truth because there's a genetic component, but this isn't a Mendelian-inherited disease. You can't draw a Punnett square and figure out what your risk is. It's multifactorial. But we do know from epidemiologic studies that having a first-degree family member with type 1 diabetes increases your risk 15-fold. So whereas one in 300 kids in the U.S. are going to be diagnosed with type 1 diabetes. If you have a first-degree family member, you have a one in 20 risk. And those are people that we really should be targeting for those autoantibodies screening. Because if you recall, I was saying we see those antibodies potentially years to a decade before the clinical disease presents itself. So, that's a perfect opportunity for us to find those patients who are going to develop type 1 insulin-requiring diabetes and use that time to either potentially intervene or to at least provide education around what are the signs and symptoms of diabetes? What does DKA look like to try and prevent the incidence of it at diagnosis? And then also, just to take some of that stress around that diagnosis and now needing to learn. It's a lot easier to teach people the skill sets around diabetes when they're not in a crisis.

Host: What other resources can we let the primary care physicians know about for the family themselves? A lot of families, of course, find themselves, right? They're going to find Facebook groups and whatnot to help with information. Do you have any pearls of wisdom, whether that's literature or whether those are groups to get together so that families feel supported?

Dr. Ryan McDonough: So first, we love people not to google, right? You're going to find bad stuff when you just go to the internet. But the internet obviously has great resources. The American Diabetes Association, diabetes.org, is probably the premier U.S.-based organization for diabetes experts and knowledge. The Type 1 Diabetes Exchange is also a really great resource. And then here locally, we've got great philanthropic organizations that also have national branches like JDRF, which now is known as Breakthrough T1D, or Kids with Courage, another great organization that is a KC-based local group that helps families in that initial period of diagnosis to connect to understand that they're not alone. And those are some really great options out there that provide good information for people to work with.

Host: Well, Dr. McDonough, thank you so much for your time today. Before I let you go with the guests that I have, I often will play Would You Rather? And this one's going to be a brutal one for you. I can already tell because I know that you are heavily invested in spending a week at Diabetes Camp. Love that. You also apparently headed off to Ireland and spent some time in Dublin and saw Taylor Swift. Holy bananas! I've had the opportunity to go to Dublin a couple of times. I mean, that alone, just going is great, but then you got to see a great concert. I got to ask would you rather?

Dr. Ryan McDonough: I would always pick Diabetes Camp.

Host: I knew that that was going to be your answer, because I know you well, and I know that that's absolutely the case. Well, thankfully, you didn't have to make that choice. You got to do both. So, that's fantastic. Again, Dr. McDonough, thank you again for joining us today.

As a reminder, to claim your CME credit for listening to today's show, go to cmkc.link/cmepodcast, and then click the claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.