The Indian Journal of Pediatrics https://doi.org/10.1007/s12098-018-2614-3
REVIEW ARTICLE
Pediatric Endocrinology in India: Development, Progress, Problems and Challenges Meena P. Desai 1 & Vijayalakshmi Bhatia 2 Received: 7 June 2017 / Accepted: 3 January 2018 # Dr. K C Chaudhuri Foundation 2018
Abstract The exponential growth of biological sciences and biotechnology has promoted the development of subspecialties / super specialties in medicine. In developing countries, socioeconomic factors influence and determine competing health priorities, often delaying the development of subspecialties in medicine. Tracing the history of development and progress of Endocrinology in general and Pediatric Endocrinology in particular, provides an overall perspective of the problems and challenges which lie ahead. Keywords Pediatric endocrinology . India . History
At times, opportunities for sequential thoughts and writing are far greater and more rewarding.
[Norman Cousins, In: Berman PL and Goldman C, eds. The Ageless Spirit, 1st ed. New York: Ballantine Books; 1992. p. 43–9.] Endocrinology as a specialized branch of internal medicine began almost five decades ago in India. Postgraduate residency training programs offering DM in endocrinology were initiated at Post Graduate Institute of Medical Education and Research, Chandigarh in 1969 [1], followed by DM courses and fellowships in endocrinology and metabolism at many teaching institutions in Delhi, Vellore, Mumbai, Varanasi, Srinagar, Lucknow and other cities. The Endocrine Society of India (ESI) was established in 1970–71 [1]. Compared to internal medicine, the development of subspecialties in pediatrics in India has lagged behind. Pediatricians interested
* Meena P. Desai
[email protected] 1
Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Institute of Child Health & Research Centre, Parel, Mumbai, India
2
Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
in specializing went abroad for training and on their return worked hard to carve a niche for themselves in teaching institutions or multispecialty private hospitals, often looking after pediatric problems while pursuing their respective specialties. Tracking the early history of development of pediatric endocrinology as a subspecialty in other parts of the world is interesting [2]. In most countries, pediatricians interested in this subject after attending international endocrinology meetings got together to form groups and decided to gain recognition for this subspecialty. The formal creation of a pediatric endocrinology group had its beginnings in Europe. Professor Andrea Prader from Kinderspital in Zurich was very disappointed with the Acta Endocrinologica Congress in Geneva as no pediatric topics were included [3]. In Europe in Zurich in July 1962, under his leadership the ‘Pediatric Endocrine Club’ (PEC) was formed. For the first time, 32 young European investigators got together in 1963 at a meeting organized by him. Thereafter these meetings were held every year in different cities of Europe. Professor Henk Visser presided over the meeting in Groningen; for the first time several pediatricians from Britain including Sir Douglas Hubble, editor of the first European textbook of pediatric endocrinology (1969) participated [4]. The title PEC was changed to European Society for Pediatric Endocrinology (ESPE) officially in 1965 [4]. The British Pediatric Endocrine Group was first convened in 1972 and renamed ‘The British Society for Pediatric Endocrinology and Diabetes’ in 1979 [5]. Meanwhile, from the early part of the twentieth century, interest in this subject was gradually evolving at many
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universities in North America prior to the era of Professor Lawson Wilkins, considered the father of pediatric endocrinology in North America. The first pediatric endocrine clinic was established by him at the Harriet Lane Home, John Hopkins University in Baltimore, USA in 1935 [5, 6]. Dr. Nathan Talbot did the same at the Massachusetts General Hospital in 1942. They trained many second generation pediatric endocrinologists who established several centres of excellence in this subject in USA and South America. The Lawson Wilkins Pediatric Endocrine Society (LWPES), so named to honour him, was founded by Wilkins in 1971 [5]. [This is now re-named the Pediatric Endocrine Society (PES)]. Subsequently, the Council in Diabetes and Youth, a part of American Diabetes Association, was integrated within the subspecialty of pediatric endocrinology [5]. The concept of an Australasian Pediatric Endocrine Group (APEG) was first mooted by N. Wettenhall during the first International Congress of Endocrinology in March 1980, with the official formation of APEG in 1982 in Melbourne. It soon became a legal entity, with Professor Bob Vines as president and Professor Martin Silink as secretary. The concept of forming the Asia Pacific Pediatric Endocrine Society, APPES (inclusive of Australia, New Zealand, Japan, South Korea, China, Philippines, Indonesia, Thailand, Malaysia, Singapore, Hong Kong, Vietnam, Sri Lanka and India, among others) was mooted by some of us (pediatric endocrinologists) from India with encouraging support from Dr. Chris Cowell during the pediatric endocrine meeting in Sydney in 1997. The first APPES meeting was held in Kuala Lumpur, Malaysia, in 1999. Ever since, the APPES conferences are held every 2 y, preceded by a 3 d training program for pediatric endocrine fellows from this region. The 2 major pediatric endocrine societies, the ESPE and the PES, have recently taken formal steps to create an International Consortium of Pediatric Endocrinology, the ICPE. The ICPE, which has on board all the pediatric endocrinology regional and country societies worldwide, is going to be responsible for holding the joint pediatric endocrinology international meeting which used to occur once every 4 y, either in Europe or the North American continents. From the year 2021, it will be hosted by various societies by rotation and bidding. The ICPE also has a mandate for collaborative global educational and research activities. In the field of diabetes, the counterpart is the International Society for Pediatric and Adolescent Diabetes. Set up in 1974, the ISPAD aims to promote clinical and basic science, research, education and advocacy in childhood and adolescent diabetes, and publishes the journal, Pediatric Diabetes. Coming back to the development of the specialty within India, the first national symposium on pediatric endocrinology in India was convened in 1986 by the author from Bai Jerbai Wadia Hospital for Children (BJWHC) in Mumbai, with the help of the Department of Science and Technology
(Government of India), the British Council and the Indian Council for Medical Research (ICMR). It was a grand success, with a delegate strength of 300 pediatricians from all over India. With growing interest in different aspects of pediatrics, pediatricians in India were already convening ‘subspecialty meetings’ with encouragement from the Indian Academy of Pediatrics (IAP); hence various subspecialty chapters of the IAP were formed officially in 1987. The second three day international symposium was also organized in Mumbai in 1989 at BJWHC, with guest faculty from the Institute of Child Health, London. BJWHC, built in 1929 by the philanthropic donation of the Wadia family, is among the first charitable hospitals in India devoted exclusively for the care of sick children. It is also the first institution in the country to establish a division of pediatric endocrinology by 1980. Two other institutions which soon came up with pediatric endocrinology specialty clinics were the All India Institute of Medical Sciences in Delhi and Christian Medical College in Vellore; a little later at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow and subsequently in other cities. Many second generation pediatricians have now trained and specialized in this subject and have established pediatric endocrinology divisions/ departments in their respective institutions. The Pediatric and Adolescent Endocrinology Chapter of the IAP with 50 initial members was established in 1987. The legally registered title of Indian Society for Pediatric and Adolescent Endocrinology (ISPAE) was adopted in 2007. Many members from all over the country (now about 400) participate actively in the biennial 3 d ISPAE conferences held by rotation in different cities which are preceded by a 2 and a 1/2 d pediatric endocrine residential training programme (PET) enrolling around 40 lecturers, assistant professors and young pediatricians doing fellowship in the subject at teaching institutions or multispecialty private hospitals having pediatric endocrinology division. A few trainees from the APPES region also register. The faculty in these biennial conferences consists of senior pediatric endocrinologists from India as well as two senior professors from ESPE and APPES each. A yearly midterm meeting with a specific theme is also held by rotation in different cities and towns. ISPAE also participates in the Chapter Symposia and specialty sessions in annual conferences of IAP and ESI. All these efforts have led to greater awareness about the various endocrine problems faced by children and adolescents in this country, leading to early referrals to appropriate centres. Though still inadequate, there are now more than 12 to 15 well organized and recognized divisions/departments of Pediatric Endocrinology in India, with over 30–40 pediatric endocrinologists working at these centres. In addition, there are about 50 to 60 pediatric endocrinologists, trained in India and overseas, who work in private clinics and multispecialty hospitals. The establishment of pediatric endocrinology fellowship of 1–2 y
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duration in Lucknow, Pune, Bengaluru, Mumbai, Delhi and other cities has added to the manpower in the country. Many of the pediatric endocrine centres or specialists are taking up focused areas of research/collating data based on clinical experience. Their publications on a number of topics relevant to India and also globally, have appeared in good impact in national and international journals. Some of our colleagues have also been represented in international working group meetings and consensus guidelines [7, 8]. To establish DM in pediatric endocrinology at various centres in India would be the next major milestone to look forward to. Though thorough clinical evaluation is the first step in reaching diagnosis, development of radio immunoassays in 1960s has helped the study of the physiology and feedback control of hormone systems, hormone production rates and metabolism, as well as detection of hormones even in low concentrations [9]. This has facilitated diagnosis in subclinical states. Sophisticated imaging techniques like ultrasonography, Doppler studies and radioisotope technology have helped unravel the underlying pathogenesis. Molecular genetic technologies have led to cloning of genes and other mutations for most hormones and their receptor systems adding to the understanding of constitutive activation or inactivation of genes as well as receptor deficiency and resistance syndromes [10, 11]. Today, there is a growing focus on the role of molecular genetic technologies in the causation of endocrine disorders. One of the examples of this is the activating and inactivating mutation of TSH receptor causing congenital hyper or hypothyroidism. Application of modern immunologic techniques has successfully demonstrated autoimmune pathogenesis for a number of endocrine disorders [12, 13]. Majority of endocrine disorders are due to hormone excess or deficiency states which may have underlying genetic or immunologic basis or could be idiopathic. Considering the current demographic pattern and as per the 2011 census, childhood and adolescent age group up to 18 y of age constitutes nearly 42 to 46% of the population of India. Though endocrine disorders in children individually may be uncommon in comparison to communicable diseases, given the large population of India, absolute numbers of many of these are likely to be high. A rough estimate suggests that there are at least 3 million children and adolescents suffering from endocrine disorders. Many of these disorders are congenital / developmental due to faulty embryogenesis or inherited due to genetic abnormalities or a combination of both. They need careful and diligent management by pediatric endocrinologists all through the early years when physical growth, intellectual, emotional and psychosocial maturation is occurring at a rapid pace. Maternal endocrine/ metabolic problems can also affect the fetus with the effects manifesting at birth or soon thereafter e.g., transient neonatal hypoglycemia or hypocalcemia in babies of mothers with diabetes or hyperparathyroidism or transient hypo or hyperthyroidism due to maternal thyroid disease or due to
drugs required for maternal treatment. Therapies for fetal hyperthyroidism, hypothyroidism and fetal adrenal hyperplasia have been developed and experimental approach for therapy of fetal growth retardation is ongoing [14, 15]. Many common problems need referral to pediatric endocrine services. Short stature which is multi factorial due to endocrine and non endocrine disorders, constituting almost 40% and thyroid disorders about 20% of all referrals. Amongst thyroid disorders hypothyroidism, simple goiters are most frequent with hyperthyroidism in 2–5%. Disorders of sex development (DSD) and early and late puberty are common causes for referral. Obesity which is often a familial, exogeneous and lifestyle disorder is encountered in around 10% to even 25% of children in some socio-economic groups, with very small percent of these children having endogenous hypothalamic or genetic syndromic causes. Type 1 and type 2 diabetes, polycystic ovary disease and metabolic syndrome are the newly emerging public health problems in India and globally. India is home to one of the largest number of diabetic children in any one country. With increasing awareness, neonatal diabetes often due to genetic mutations is also being identified more frequently. Though uncommon, persistent hyperinsulinemic hypoglycemia of infancy which can be life threatening is being detected early. Small for gestational age, which constitutes almost 25–28% of all newborns in India assumes public health dimensions in our country as these are the harbinger of future issues related to growth, early onset of puberty, PCOS, metabolic syndrome, hypertension, type 2 diabetes and cardiovascular problems developing during early adulthood. Research in the field of epigenetics which suggests transgenerational effect (thrifty genotype) over generations, stresses the importance of nutritional well being of the girl child and preconceptional maternal health. Survivors of childhood cancer form a large group in India now, requiring special follow up by a pediatric endocrinologist / endocrinologist. Development of neonatal screening (NBS) for endocrine/ metabolic disorders is one of the most important and costeffective strategies for prevention of mental and physical sequelae in some of these disorders which compromise the future of those affected. NBS was first conceived by Professor Guthrie of USA in 1960 for phenylketonuria (PKU) [16]. To this, screening for congenital hypothyroidism (CH) was added in 1965 [17]. Today universal neonatal screening for endocrine and metabolic disorders is well established in many developed countries, constituting one of the most important strategies in the field of preventive health care. As demonstrated in early 1970s, early recognition and therapy of common endocrine disorders like CH can prevent lifelong physical, mental and psychosocial sequelae [18, 19]. Presently, NBS for CH is undertaken in some institutions and private hospitals in India. Implementation of universal national programs need adequate financial resources, infrastructure, personnel and structured recall and follow up facilities. State level programs
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specifically for CH are partially established in Goa, Delhi, Gujarat, Kerala and Uttar Pradesh. The importance of clinical research and epidemiology relevant to pediatric endocrinology in India deserves mention. Examples include beginning registries for common disorders like type 1 diabetes and rare disorders such as DSD. There is a need for establishing clinical practice guidelines for management of common endocrine disorders. Diagnostic tests and therapy of some of these endocrine/ metabolic disorders are expensive. With the growing list of therapeutic agents for management of growth and pubertal disorders, availability and affordability of treatment are important issues. The pricing policies of the pharmaceutical companies have to be negotiable. Access to charitable trusts and patient support groups can go a long way in helping some of these patients. Genetic counseling and educating these patients and their families play an important part of the management of these disorders, most of which are highly amenable to treatment. Availability of lifesaving medications for children such as insulin and glucocorticoid, and common supporting laboratory tests for routine management (HbA1c and thyroid hormones) in all pediatric centers would go a long way in improving care. Training of nurses and educators in pediatric endocrinology, especially diabetes, is the need of the hour. The services made by pediatric endocrinologists towards patient awareness programs and patient support groups, for example for diabetes and congenital adrenal hyperplasia, among others, should be scaled up to serve greater populations. As with most medical disciplines, pediatric endocrinology involves lot of team work and interaction with adult endocrinologists, pediatric surgeons, neonatologists, gynecologists, geneticists, genetic counselors, psychologists, social workers, family physicians, radiologists, pathologists and trained nursing personnel. One of the recent articles suggests that pediatricians and qualified endocrinologists are opting for pediatric endocrinology as a career option [20]; the authors feel it is time to recount and chronicle the history of development and progress of this subspecialty of pediatrics in our country. India being a large resource poor country and the second most populous nation in the world with its multilingual, multicultural, multireligious and multiethnic population, it faces many problems and challenges defying solution in the near future. Hopefully the efforts and endeavours of the past will brighten the future of generations of children with these disorders.
Contributions MPD conceptualised the article, wrote the first draft, finalised the manuscript and will act as guarantor for this paper. VB assisted in researching the topic and provided inputs to the manuscript.
Compliance with Ethical Standards Conflict of Interest None.
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18. Acknowledgements The authors would like to thank Dr. Garry Warne (formerly professor of pediatric endocrinology at Royal Children’s Hospital, Melbourne) for his help in providing some of the historical aspects of development of pediatric endocrinology in Europe and Australia. They would also like to thank Dr. Ruchi Parikh, pediatric endocrinologist (assistant honorary, division of pediatric endocrinology at Bai Jerbai Wadia Hospital for Children, Mumbai) for her assistance.
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