|Year : 2019 | Volume
| Issue : 6 | Page : 490-494
Retrospective review of presentation of newly diagnosed children with diabetes mellitus in a Nigerian rural setting
Umar Isa Umar1, Isyaku Lawal Muhammed2, Ibrahim Aliyu1
1 Department of Paediatrics, College of Health Sciences, Bayero University; Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Nguru, Yobe, Nigeria
|Date of Submission||09-Nov-2018|
|Date of Acceptance||29-Mar-2019|
|Date of Web Publication||17-Oct-2019|
Umar Isa Umar
Department of Paediatrics, Aminu Kano Teaching Hospital, P. M. B. 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus (DM) is the common endpoint of a variety of disorders of insulin production and/or insulin action resulting in hyperglycemia with associated abnormalities of carbohydrate, fat, and protein metabolism. Presentation with diabetic ketoacidosis (DKA) may be associated with significant morbidity and mortality in the pediatric population. Objective: The objective of this study was to examine the pattern of presentation of newly diagnosed children with DM in a rural setting. Design: It was a retrospective study of case files of newly diagnosed children with DM. Patients and Methods: It was a retrospective review of case files of children younger than 18 years with diagnosis of DM, over a 2-year period (from November 1, 2015, to October 31, 2017) at Federal Medical Centre Nguru, Yobe State, North-Eastern Nigeria. Results: A total of 3289 patients were seen during the study period, of which 6 were diagnosed with DM, giving a case prevalence rate of 1.8/1000. The mean age at presentation was 11.1 (±0.8) years, and there were four males and two females among the patients. All of the patients presented in DKA, and other prevalent presenting features were polyuria (6, 100%), polydipsia (6, 100%), dehydration (6, 100%), weight loss (100%), fever (83.3%), and weakness (4, 66.7%). Two of the six patients with DKA died from cerebral edema, and one had acute kidney injury during admission. Conclusion: Presentation with DKA is common in this setting despite the glaring symptoms of DM, such as polyuria, polydipsia, and weight loss. This highlights the need for intensified efforts in education of health workers and the populace at large for quick recognition, presentation, and prompt diagnosis for optimal management of childhood DM.
Keywords: Clinical presentations, diabetes mellitus, diabetic ketoacidosis, Nigeria, rural setting
|How to cite this article:|
Umar UI, Muhammed IL, Aliyu I. Retrospective review of presentation of newly diagnosed children with diabetes mellitus in a Nigerian rural setting. Med J DY Patil Vidyapeeth 2019;12:490-4
|How to cite this URL:|
Umar UI, Muhammed IL, Aliyu I. Retrospective review of presentation of newly diagnosed children with diabetes mellitus in a Nigerian rural setting. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2020 Aug 5];12:490-4. Available from: http://www.mjdrdypv.org/text.asp?2019/12/6/490/269421
| Introduction|| |
Diabetes mellitus (DM) is the common endpoint of a variety of disorders of insulin production and/or insulin action resulting in hyperglycemia with associated abnormalities of carbohydrate, fat, and protein metabolism., It has been described as a public health challenge of the 21st century, with a reported global prevalence of 8.3%, which translates to about 387 million people living with DM globally, of which 46.3% remained undiagnosed. Type 1 DM (T1DM) remains the most common form of diabetes in childhood and is caused by insulin deficiency following autoimmune destruction of the insulin-producing pancreatic beta-cells. Although it commonly presents in childhood, one-fourth of cases are diagnosed in adults.,, Worldwide, DM is one of the most common chronic diseases in children and T1DM accounts for over 90% of the cases. The incidence of T1DM in children varies widely, and the incidence rates are correlated with the frequency of human leukocyte antigen susceptibility genes in the general population., It is higher in Caucasian populations and in populations distance from the equator. Countries with the highest annual incidence rates of T1DM in children are Finland, Sweden, Canada, and Norway. In Africa, the reported incidence is low, even though DM is not rare in Africa, but there is limited information from the region. In Nigeria, the incidence and pattern of presentation of childhood diabetes are limited and poorly documented, with regional variations reported from various studies. A hospital prevalence of 1.6/1000 in Port Harcourt, South Nigeria, and 0.1/1000 in Abakaliki, Southeast Nigeria, has been reported. In Sokokto, Northwest Nigeria, a hospital prevalence rate of 0.33/1000 was reported by Ugege et al., and Umar from Kano reported 2.3/1000.
Childhood diabetes may present with polyuria, polydipsia, and polyphagia, along with lassitude, nausea, and blurred vision, all of which result from the effect of hyperglycemia. However, the onset of symptoms may be sudden and is not unusual for some patients to present with diabetic ketoacidosis (DKA), which may occur de novo or following illnesses, such as malaria, sepsis, or surgery.
This study aims to examine the pattern of presentation of newly diagnosed children with DM in a rural setting over a 2-year period.
| Patients and Methods|| |
The study involved a retrospective review of case note of all children diagnosed and managed as cases of DM in the Paediatric Department of Federal Medical Centre, Nguru, between November 2015 and October 2017. An ethical approval was obtained from the Ethical and Research Committee of the hospital, and the study was performed according to the Declaration of Helsinki. Childhood DM was diagnosed by the presence of symptoms of DM and a random blood glucose ≥11.1 mmol/l. DKA was diagnosed by significant hyperglycemia (≥11 mmol/l), ketonuria, serum bicarbonate <15 mmol/l, and DKA-associated clinical signs (e.g., dehydration and Kussmaul respiration, among others). Data retrieved from the case notes included the following: age, sex, presenting symptoms, duration of symptoms prior to presentation, and outcome of hospitalization. The results of random plasma glucose, serum electrolytes, and urinalysis were also recorded.
The data were entered into Statistical Package for the Social Sciences version 20.0 (IBM Corp. Armonk, New York, United States of America). Descriptive analysis of frequency distributions of qualitative variables was tabulated, whereas mean and standard deviation (SD) for quantitative variable were calculated.
| Results|| |
Six cases of childhood DM were seen of 3289 admissions during the 2-year period, indicating a hospital prevalence of 1.8/1000 per year. The study participants were between the ages of 11 and 12 years, with a mean (± SD) age of 11.1 (±0.8) years. There were more males (4/6) than females (2/6) among the participants [Table 1]. No family history of DM was found in any of the participants. All the participants presented with a history of polyuria (6, 100%), polydipsia 6 (100%), and weight loss (100%), and majority had fever (5, 83.3%) and weakness (4, 66.7%). Other presenting features are shown in [Table 2]. Duration of hospital stay ranged from 7 to 30 days with a mean of 15.5 (±8.3) days. [Table 3] shows the indications for admissions; all of the six diabetic patients had DKA (100%), severe malaria was the precipitating factor in three of the six patients with DKA and two of the six patients died from cerebral edema and one had acute kidney injury during admission.
|Table 2: Common presenting clinical features in patients with diabetes mellitus|
Click here to view
|Table 3: Indication for admission, outcome, and precipitating factor for diabetic ketoacidosis|
Click here to view
| Discussion|| |
The principal finding in this study was that all the children (100%) had DKA at presentation. This finding is the highest reported from studies in Africa and other developing countries. Local studies in Nigeria reported various frequencies of DKA: Abakaliki (88%), Sokoto (62.5%), Jos (75%), and Kano (89%). Similarly, some studies from other developing countries such as Romania (67%), South Africa (69.8%), the United Arab Emirates (80%), Tanzania (90%), and Congo (90%) have reported high frequencies of DKA, but none was as high as in this study. The finding of DKA in all our diabetic patients may be explained by the possible lack of awareness of signs and symptoms of DM in children among parents coupled with intercurrent infections, poverty, in addition to poor health services with late diagnosis, and poor management prevalent in the rural area. Furthermore, this study area is one of the affected regions by Boko Haram insurgency in Northeastern Nigeria. Moreover, it is a known fact that insurgency constitutes the highest contributor to humanitarian crises resulting in increasing human casualties, spread of various diseases, poverty, and other serious social problems. Illiteracy may also be contributory because countries with a higher level of awareness among parents, coupled with good and affordable health services, often experienced early diagnosis of DM and observed lower frequencies of DKA (14% in Sweden and 26% in US). This is not surprising, as there is robust evidence for a similar relationship between life expectancy and Gross Domestic Product (GDP), with poorer countries accounting for the largest share of the global disease burden. Other observations among the participants in this study were history of polyuria (6, 100%), polydipsia (6, 100%), dehydration (6, 100%), weight loss (100%), fever (5, 83.3%), and weakness (4, 66.7%).
This study found a prevalence of diabetes of 1.8/1000, which was lower than the 10.1/1000 reported by John et al. in a similar hospital-based study in Jos, north-central Nigeria. Our finding was, however, higher than the 0.33/1000 reported by Afoke et al. of T1DM among children in Ishiellu, Southeastern Nigeria, and Ugege et al. in Sokoto, Northwestern Nigeria, who also reported a prevalence of 0.33/1000 among children. This low prevalence was also in tandem with the few epidemiological studies on T1DM in African children; Tanzania was estimated to have a prevalence of 1.5/100,000. However, this finding may not be a true reflection of the actual population prevalence because these were hospital-based retrospective data. The diagnosis of DM may have been missed in the hospital or children may have already died before they reached the hospital. Furthermore, low prevalence of DM had been postulated to be due to reduced genetic susceptibility to DM among Black African, a finding also observed among Afro-Americans., The other contributory factors could be the high mortality among African children with T1DM; in rural Mozambique, life expectancy was reported to be as low as 0.6 years.
The study found a male preponderance, with 4 (66.7%) males versus 2 (33.3%) females, such a male preponderance was observed in Saudi Arabia by Abdullah, with a male-to-female ratio of 1.3:1. On the contrary, some studies reported female preponderance; Umar in Northwestern Nigeria found 72.2% females versus 27.8% in his study, and also in the series reported by Salman et al. in Riyadh Saudi-Arabia, wherein 53.6% of patients were female. In general, there are no significant gender differences in the incidence of DM. However, a male gender bias is often observed in older adolescents and young adults.,,
In most participants, the apparent trigger for DKA was infection. This ranged from urinary tract infection, malaria, and septicemia. Other documented precipitating factors include newly diagnosed DM, poor insulin administration, and stressful conditions. The outcome of participants in this study was not encouraging, as only 66.7% were discharged to follow-up, two died from DKA from cerebral edema, and one had acute kidney injury with prolonged hospital stay.
| Conclusion|| |
Presentation with DKA was common in this setting despite the glaring symptoms of DM: polyuria, polydipsia, and weight loss. However, a relatively low prevalence of DM in children was found, but this finding may not be a true reflection of the actual population prevalence on account of this being a hospital-based retrospective data. Moreover, the diagnosis of DM may have been missed in the hospital or children could have already died before they reached the hospital. Therefore, there is a pressing need to decrease the excessive morbidity, mortality, and health-care expenditure associated with DKA in this region and other lower socioeconomic countries. This can be achieved through community intervention by improving awareness of childhood diabetes among schoolchildren, parents, and health-care providers. Better disease recognition through improved awareness of DM is also supported by the findings that children from families with higher parental education are less likely to present in DKA and having a first-degree relative with diabetes is associated with up to six-fold decreased risk of DKA at diagnosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 1:S81-90.
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49.
Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010;87:4-14.
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.
Lipton RB, Drum M, Burnet D, Rich B, Cooper A, Baumann E, et al.
Obesity at the onset of diabetes in an ethnically diverse population of children: What does it mean for epidemiologists and clinicians? Pediatrics 2005;115:e553-60.
Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, et al.
Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective. J Pediatr 2000;136:664-72.
Duncan GE. Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002. Arch Pediatr Adolesc Med 2006;160:523-8.
Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC, et al.
ISPAD clinical practice consensus guidelines 2014. Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes 2014;15 Suppl 20:4-17.
Ilonen J, Reijonen H, Green A, Reunanen A, Knip M, Simell O, et al.
Geographical differences within Finland in the frequency of HLA-DQ genotypes associated with type 1 diabetes susceptibility. The childhood diabetes in Finland study group. Eur J Immunogenet 2000;27:225-30.
Kukko M, Virtanen SM, Toivonen A, Simell S, Korhonen S, Ilonen J. Geographical variation in risk HLA-DQB1 genotypes for type 1 diabetes and signs of beta-cell autoimmunity in a high-incidence country. Diabetes Care 2004;27:676-81.
Josephine HO, Christopher TF, Daniele P, Alexander KC. Type 1 diabetes mellitus in children and adolescents: Part 1, overview and diagnosis. Consultant360 2010;9:55-9.
Elamin A, Omer MI, Hofvander Y, Tuvemo T. Prevalence of IDDM in schoolchildren in Khartoum, Sudan. Diabetes Care 1989;12:430-2.
Opara PI, Anochie IC, Eke FU. Childhood diabetes mellitus in Port-Harcout: Any change in prevalence and outcome? Port Harcourt Med J 2008;21:126-9.
Ibekwe UM, Ibekwe CR. Pattern of type 1 diabetes mellitus in Abakaliki, Southeastern, Nigeria. Pediatr Oncall J 2011. [Serial online]. Art #48. Available from: http://www.pediatriconcall.com/pediatric-journal
. [Last accessed on 2011 July 01].
Ugege O, Ibitoye PK, Jiya NM. Childhood diabetes mellitus in Sokoto, North-Western Nigeria: A ten year review. Sahel Med J 2013;16:97-101. [Full text]
Umar UI. Pattern of presentation of type 1 diabetic patients in Kano, Nigeria. Niger J Basic Clin Sci 2016;13:858.
Ayoola OO. Recent advances in childhood diabetes mellitus. Ann Ib Postgrad Med 2008;6:9-20.
John C, Abok II, Yilgwan C. Clinical profile of childhood type 1 diabetes in Jos, Nigeria. Afr J Diabetes Med 2013;21:148-51.
Usher-Smith JA, Thompson M, Ercole A, Walter FM. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: A systematic review. Diabetologia 2012;55:2878-94.
Reddy Y, Ganie Y, Pillay K. Characteristics of children presenting with newly diagnosed type 1 diabetes. S Afr J CH 2013;7:46-8.
Majaliwa ES, Munubhi E, Ramaiya K, Mpembeni R, Sanyiwa A, Mohn A, et al.
Survey on acute and chronic complications in children and adolescents with type 1 diabetes at Muhimbili National Hospital In Dar es Salaam, Tanzania. Diabetes Care 2007;30:2187-92.
Otieno CF, Kayima JK, Omonge EO, Oyoo GO. Diabetic ketoacidosis: Risk factors, mechanisms and management strategies in Sub-Saharan Africa: A review. East Afr Med J 2005;82:S197-203.
Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden – A 2-year paediatric population study. Diabet Med 2007;24:1080-5.
Bui H, To T, Stein R, Fung K, Daneman D. Is diabetic ketoacidosis at disease onset a
result of missed diagnosis? J Pediatr 2010;156:472-7.
Swift R. The relationship between health and GDP in OECD countries in the very long run. Health Econ 2011;20:306-22.
Afoke AO, Ejeh NM, Nwonu EN, Okafor CO, Udeh NJ, Ludvigsson J. Prevalence and clinical picture of IDDM in Nigerian Igbo schoolchildren. Diabetes Care 1992;15:1310-2.
Majaliwa ES, Elusiyan BE, Adesiyun OO, Laigong P, Adeniran AK, Kandi CM, et al.
Type 1 diabetes mellitus in the African population: Epidemiology and management challenges. Acta Biomed 2008;79:255-9.
Mac Donald MJ. Lower frequency of diabetes among hospitalized Negro than white children: Theoretical implications. Acta Genet Med Gemellol (Roma) 1975;24:119-26.
Dunston GM, Henry LW, Christian J, Ofosu MD, Callender CO. HLA-DR3, DQ heterogeneity in American blacks is associated with susceptibility and resistance to insulin dependent diabetes mellitus. Transplant Proc 1989;21:653-5.
Beran D, Yudkin JS, de Courten M. Access to care for patients with insulin-requiring diabetes in developing countries: Case studies of Mozambique and Zambia. Diabetes Care 2005;28:2136-40.
Abdullah MA. Epidemiology of type I diabetes mellitus among Arab children. Saudi Med J 2005;26:911-7.
Salman H, Abanamy A, Ghassan B, Khalil M. Insulin-dependent diabetes mellitus in children: Familial and clinical patterns in Riyadh. Ann Saudi Med 1991;11:302-6.
Zeitler P, Fu J, Tandon N, Nadeau K, Urakami T, Barrett T, et al.
ISPAD clinical practice consensus guidelines 2014. Type 2 diabetes in the child and adolescent. Pediatr Diabetes 2014;15 Suppl 20:26-46.
Arslanian S. Type 2 diabetes in children: Clinical aspects and risk factors. Horm Res 2002;57 Suppl 1:19-28.
Rodriguez BL, Fujimoto WY, Mayer-Davis EJ, Imperatore G, Williams DE, Bell RA, et al.
Prevalence of cardiovascular disease risk factors in U.S. Children and adolescents with diabetes: The SEARCH for diabetes in youth study. Diabetes Care 2006;29:1891-6.
Haynes A, Bulsara MK, Bower C, Codde JP, Jones TW, Davis EA. Independent effects of socioeconomic status and place of residence on the incidence of childhood type 1 diabetes in Western Australia. Pediatr Diabetes 2006;7:94-100.
Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ 2011;343:d4092.
[Table 1], [Table 2], [Table 3]