For Pediatric Endocrinology, Early Referral is Crucial

David Repaske, MD, is a pediatric endocrinologist at UVA Health Children's. He shared his perspective on why endocrinology is a rewarding specialty, why early referral is so important, and what everyone should know about the early indicators of endocrine problems like diabetes.

What made you decide to focus on pediatric endocrinology? 

I had a PhD in Biochemistry from the University of Wisconsin – Madison before attending medical school at Vanderbilt.  In medical school, I gravitated toward the Pediatricians’ personalities and wanted to continue research. Endocrinology is very close to biochemistry, with the hormones and pathways. It was a natural fit.

What’s your favorite thing about practicing as a pediatric endocrinologist? 

Two things: Being able to do something different every day, and having long-term relationships with my Pediatric Endocrinology patients and families. Some days are focused on clinic patients, some on medical education, some on clinical research, and some on administration.

How can referring providers help their patients with early detection and diagnosis? 

Diabetes is most amenable to early detection and diagnosis.  For Type 2 Diabetes, following the patient’s BMI on the growth curve: if it is crossing centiles upward, refer the child to our Diabetes Prevention Clinic early on for the best chance of interrupting progression to Type 2 Diabetes.  

For Type 1 Diabetes, early detection is through screening for islet cell autoantibodies. Two positive antibodies all but guarantee the development of symptomatic diabetes in the future. And 90% of patients have no family history, so everyone should be screened, not just those with relatives with Type 1 Diabetes. Knowing that Type 1 Diabetes is coming allows education for the family and reduces the rate of DKA at symptomatic onset dramatically.  And we now have an approved medication that can postpone, but not yet prevent, the development of Type 1 Diabetes, if these pre-symptomatic patients have been identified by screening.   

What risk factors should referring providers be on the lookout for? 

For Type 1 Diabetes, a family history of Type 1 Diabetes or a personal history of celiac disease or Hashimoto thyroiditis raises the risk for future development.  
These children should be screened for islet autoantibodies for early identification of pre-symptomatic Type 1 Diabetes

What’s one thing that every primary care doctor could start doing today to help their patients?  

Screen for islet autoantibodies, and plot BMI and refer early for children who have a rising BMI trajectory

When should providers refer their patients to your program?  

Early.  We want to be proactive with education and early treatment whenever possible.

What’s your approach to working with referring providers?  

It helps us and your patients when the referring provider sends growth charts and lab assessments when patients are first referred.  We triage and see urgent patients within hours or days. 

 We triage to the clinician and clinic session that is most appropriate for the patient.  We have extended appointment times, typically 40 minutes, to get to know the family, conduct a thorough evaluation, educate the family on our differential diagnosis, and begin a further investigation, when appropriate.

What’s one thing UVA Health Children's can offer these patients that you think makes their experience better?  

Two things: We have a great group of caring physicians with a wide range of expertise, and we have opportunity for patients to enroll in a wide variety of clinical trials for early access to novel therapies. We have providers here with expertise in diabetes, in obesity/diabetes prevention, in metabolic bone disease, in PCOS, in adrenal disorders, in gender health, in cystic fibrosis diabetes, in pituitary diseases, in growth and development, in puberty abnormalities, and in general endocrinology (thyroid, calcium, hypoglycemia). And we have ongoing clinical research in most of these areas.