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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 123-126

Childhood diabetes mellitus in a rural tertiary hospital in North-West Nigeria


Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria

Date of Web Publication9-Apr-2018

Correspondence Address:
Umma Abdullahi Idris
Department of Paediatrics, Federal Medical Centre, Birnin Kudu, Jigawa State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_61_17

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  Abstract 


Background: Childhood diabetes mellitus (DM) has been described among children in developed world, with a very scant report among African children, especially those in rural areas. Aim: This study aimed to describe the prevalence, presentation, and outcome of DM among children seen in a rural tertiary hospital in North-West Nigeria. Materials and Methods: This was a 10-year retrospective study of children with DM seen in the Pediatric Department of Federal Medical Centre, Birnin Kudu, Jigawa State, Nigeria. Relevant demographic data, clinical presentation, and outcome were extracted and analyzed. Results: Nine of the 6269 of the children admitted during the study period had Type 1 DM, giving a prevalence of 1.4/1000 admissions. The mean age was 12.7 years, with a slight female preponderance. The mean duration of symptoms prior to presentation was 13.7 days and all the patients presented with diabetes ketoacidosis (DKA). All the patients recovered fully and were discharged to endocrine clinic, but only three children are being followed up. Conclusion: DKA was the only mode of presentation among children with DM in this series, with surprisingly excellent outcome but a high default rate.

Keywords: children, Diabetes mellitus, Nigeria, Rural


How to cite this article:
Idris UA. Childhood diabetes mellitus in a rural tertiary hospital in North-West Nigeria. CHRISMED J Health Res 2018;5:123-6

How to cite this URL:
Idris UA. Childhood diabetes mellitus in a rural tertiary hospital in North-West Nigeria. CHRISMED J Health Res [serial online] 2018 [cited 2019 Mar 21];5:123-6. Available from: http://www.cjhr.org/text.asp?2018/5/2/123/229589




  Introduction Top


Diabetes mellitus (DM) is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both.[1]

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.[2] Worldwide, about 65,000 children <15 years of age have type 1 DM and this is increasing at a rate of 3%/year.[3] Type 2 diabetes (T2DM) is caused by a relative insulin deficiency resulting from the insulin-resistant state of obesity.[4]

There is a wide global variation in the incidence of T1DM in children aged <14 years, with very high incidences reported from Finland and the United Kingdom and with an incidence of 20/100,000 and as low as <1/100,000 in China and South America.[3] The overall prevalence of TIDM type 1 diabetes in Karnal district in India is 10.20/100,000 population, with a higher prevalence in urban (26.6/100,000) as compared to rural areas (4.27/100,000).[5] The prevalence among healthy African schoolchildren (aged 7–11 years) is reported to be 0.3–0.95/1000.[6]

Presentation of T1DM may be insidious with features mainly due to hyperglycemia (polyuria, polydipsia, polyphagia, or weight loss) or an acute presentation in the form of diabetes ketoacidosis (DKA).[1] DKA is associated with significant morbidity and mortality in children. The frequency of DKA at the initial diagnosis of T1DM ranged from 15% to 90% with mortality of 0.15%–0.3% in developed countries and is as high as 26% in developing ones, notably Ghana, Tanzania, and Kenya.[6]

The reported prevalence and incidences of childhood T1DM from Africa are few and and mainly conducted in urban areas with high level of awareness and improved access to health-care facilities compared to rural areas.

This study aimed to determine the prevalence, clinical presentation, and outcome of children with T1DM.


  Materials and Methods Top


This study uses secondary data of all the children with T1DM aged 1 month–14 years admitted into the emergency pediatric unit (EPU) of the Federal Medical Centre, Birnin Kudu, from June 2007 to May 2017. It is the only federal tertiary government hospital that provides inpatient service in Jigawa State and its neighboring state. It was established in the year 2000 for the provision of service, teaching, and research to cater for the needs of the local and wider community. The EPU has a capacity of 14 beds where all sick children are admitted. Parents or guardians bear all the cost of admissions including drugs, antibiotics, and investigations.

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 diabetes was diagnosed by the presence of symptoms of diabetes and a random blood glucose (>11.1 mmol/L) or fasting plasma glucose level >7.0 mmol/L. DKA was diagnosed by significant hyperglycemia (>14 mmol/L), ketonuria, serum bicarbonate <15 mmol/L, and DKA-associated clinical signs (e.g., dehydration and Kussmaul's respiration).[1] Patients with DKA were managed according to the departmental protocol of DKA management. The treatment protocol is based on the assumption of 5%–10% fluid loss. The initial bolus of 20 ml/kg of 0.9% saline is given, and then the remaining fluid balance (deficit plus maintenance) is spread over the next 24–36 h. The fluid is changed to 0.18% in 4.3% dextrose when blood glucose falls to <14 mmol/L. Potassium is added to replacement fluid after the bolus and then adjusted appropriately based on serum level. Insulin infusion is started at 0.1 units/kg/h and then reduced to 0.05 units/kg/h when blood glucose falls to 14 mmol/L. We then switch to 0.05 units/kg every 6 h before meal and ultimately to morning and evening doses as 2/3rd and 1/3rd of the total insulin dose in previous day, respectively. Antimicrobials are started to treat any precipitating factor. We usually aim to treat DKA for 36–48 h.

Data retrieved from the case notes include age, sex, presenting symptoms, duration of symptoms prior to presentation, weight, and outcome of hospitalization. The outcome is discharge following full recovery, discharge against medical advice, or death.

The socioeconomic status of the patient was determined by modifying the Oyedeji classification based on the educational attainments and occupations of parents or their substitutes.[7]

Using the weight for age (WFA) percentile, underweight was defined as WFA <5th percentile of the National Centre for Health Statistics reference standard, normal weight as 5th–85th percentile, overweight as >85th–95th percentile, and obesity as >95th percentile.[8]

Descriptive statistics such as frequencies, means, ratios, standard deviation, and percentages were used to describe all the variables.


  Results Top


Nine out of 6269 children admitted in the EPU during the study period had DM, giving a hospital prevalence of 1.4/1000 admissions. There is a slight female preponderance of 5/9 among children with T1DM [Table 1]. The mean age was 12.7 years, with a range of 9–14 years. All the nine children with T1DM were from low socioeconomic class. Seven (78%) of the children were underweight while two (22%) had normal WFA on admission. No child was overweight or obese.
Table 1: Age and sex distribution of children with diabetes mellitus

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All the nine children presented with DKA. The most common presenting features were weight loss and dehydration as shown in [Figure 1].
Figure 1: Common clinical features at presentation

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The mean duration of symptoms prior to presentation was 13.7 days and the patients spent an average of 16 days during hospitalization.

Only one patient had a family history of DM. Following full recovery, all the nine patients were discharged home on subcutaneous Mixtard ® insulin after adequate counseling. Six of the nine patients were lost to follow-up [Table 2].
Table 2: Family history, precipitating factors, and outcome (n=9)

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  Discussion Top


The prevalence of T1DM in this study conducted in a rural tertiary facility was found to be 1.4/1000. This reported prevalence in this study may not reflect that of the population due to the fact that it is a hospital-based retrospective study. Furthermore, the diagnosis may have been missed even among those who were able to make it to the facility and some may have been managed at home or have died prior to presentation. The finding in this study is lower than 2.3/1000 and 10.1/1000 in hospital studies conducted in urban areas of Kano (North-West Nigeria) and Jos (North-Central Nigeria) by Umar [9] and John et al.,[10] respectively. This is similar to reports from Indian state of Kalmar where lower prevalence of T1DM was observed among children in the rural areas compared to those who reside in urban region.[5] The rural–urban disparity in the prevalence of the T1DM may be due to geographical variation, ignorance, poor access to health-care facilities, and high rates of poverty among the rural dwellers. Perhaps, those who reside in urban areas are more likely to be educated, have increased access to health-care facilities, and are more likely to present for early diagnosis and prompt treatment. Similar urban dominance of DM was also reported among adults in Africa and Asia. Further studies may answer this question in the context of childhood diabetes.

Similar to the previous studies,[9],[11],[12],[13] this study also found a slight female preponderance. The reason for the female dominance is not very clear although some researchers have implicated hormones and high-level cytokines as the reason.[14]

The mean age in this study was 11.7 years which is similar to findings of other authors in Nigeria.[11],[12],[15] This finding, however, contrasts to the report from Iran [16] and Saudi Arabia [17] where the mean ages were 7.3 and 6.7 years, respectively. The higher age at presentation in Nigerian children may be explained by racial, ethical, and geographical differences.

All the children in this series presented with DKA at the initial diagnosis of T1DM after an average 2 weeks of symptoms. This is the first report in the literature where there is 100% of presentation of T1DM. Previous reports from Nigeria have reported the frequency of 60%–77%[9],[10],[11] and up to 90% in Tanzania [18] and Congo.[19] It was as low as 26.3% and 25.5%, respectively, in Germany and the USA.[20],[21] The disparity in the frequency of DKA in children from Africa and the developed world may be explained by racial, ethical, genetic, and environmental factors. Socioeconomic status, access to health-care services, and level of awareness of the population to T1DM in the developed countries may also be contributory. It is proposed that DKA at the onset of T1DM in children may be due to delayed diagnosis or an indication of an aggressive form of the disease.

It is worth noting that all the children in this series recovered fully and were discharged home after a variable duration of hospital stay. This is impressive given that our facility is stationed in the rural area with limited resources which showed that the outcome of the patient is excellent compared to the previous reports from Africa and even other developed countries.

However, unfortunately, most of them defaulted from follow-up. The high default rate may not be unconnected to low level of awareness of the disease, perceived improvement despite adequate counseling prior to discharge, and most importantly financial implications as all our patients pay out of pocket for their treatment and transportation costs. This is also reported from both Kano and Sokoto in North-West Nigeria. The three patients are presently being followed up only because the managing physician provides free insulin to them.


  Conclusion Top


T1DM is relatively uncommon in this locality and all the children presented with DKA.

However, despite the limitation of this study (small sample size from a single center), it has highlighted the presentation of T1DM in rural children and the surprisingly excellent outcome.

Efforts should be made at increasing the level of awareness of T1DM among parents and children and health care workers should be adequately trained in early and prompt treatment of TIDM in children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Craig ME, Hattersley A, Donaghue KC. Definition, epidemiology and classification of diabetes in children and adolescents. Pediatr Diabetes 2009;10 Suppl 12:3-12.  Back to cited text no. 1
    
2.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 11:S81-90.  Back to cited text no. 2
    
3.
WHO multinational project for childhood diabetes. WHO Diamond Project Group. Diabetes Care 1990;13:1062-8.  Back to cited text no. 3
    
4.
Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J Diabetes 2013;4:270-81.  Back to cited text no. 4
    
5.
Kalra S, Kalra B, Sharma A. Prevalence of type 1 diabetes mellitus in Karnal district, Haryana state, India. Diabetol Metab Syndr 2010;2:14.  Back to cited text no. 5
    
6.
Mbanya JC, Ramiaya K. Diabetes mellitus. In: Jamison DT, Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd ed. Ch. 19. Washington (DC): The International Bank for Reconstruction and Development/the World Bank; 2006. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2291/#. [Last accessed on 2017 oct 20].  Back to cited text no. 6
    
7.
Oyedeji GA. Socioeconomic and cultural background of hospitalized children in Ilesha. Niger J Paediatr 1985;12:111-7.  Back to cited text no. 7
    
8.
Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, et al. 2000 CDC growth charts for the United States: Methods and development. Vital Health Stat 11 2002;246:1-90.  Back to cited text no. 8
    
9.
Umar UI. Pattern of presentation of Type 1 diabetic patients in Kano, Nigeria. Niger J Basic Clin Sci [Serial online] 2016;13:85-8. Available from: http://www.njbcs.net/text.asp?2016/13/2/85/187361. [Last accessed on 2017 May 03].  Back to cited text no. 9
    
10.
John C, Abok II, Yilgwan C. Clinical profile of childhood type 1 diabetes in Jos, Nigeria. Afr J Diabetes Med 2013;21:148-51.  Back to cited text no. 10
    
11.
Ibekwe MU, Ibekwe RC. Pattern of Type 1 Diabetes Mellitus in Abakaliki, Southeastern, Nigeria. Pediatric Oncall; 2011. Available from: http://www.pediatriconcall.com. [Last accessed on 2016 Aug 25].  Back to cited text no. 11
    
12.
Onyiriuka AN, Ifebi E. Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: Frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47.  Back to cited text no. 12
    
13.
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.  Back to cited text no. 13
    
14.
Mooney RA, Senn J, Cameron S, Inamdar N, Boivin LM, Shang Y, et al. Suppressors of cytokine signaling-1 and-6 associate with and inhibit the insulin receptor: A potential mechanism for cytokine-mediated insulin resistance. J Biol Chem 2001;12:25889-93.  Back to cited text no. 14
    
15.
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.  Back to cited text no. 15
  [Full text]  
16.
Razavi Z. Frequency of ketoacidosis in newly diagnosed type 1 diabetic children. Oman Med J 2010;25:114-7.  Back to cited text no. 16
    
17.
Habib HS. Frequency and clinical characteristics of ketoacidosis at onset of childhood type 1 diabetes mellitus in northwest Saudi Arabia. Saudi Med J 2005;26:1936-9.  Back to cited text no. 17
    
18.
Majaliwa ES, Munubhi E, Ramaiya K, Mpembeni R, Sanyiwa A, Mohn A, et al. Survey 11on 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.  Back to cited text no. 18
    
19.
Monabeka HG, Mbika-Cardorelle A, Moyen G. Ketoacidosis in children and teenagers in Congo. Sante 2003;13:139-41.  Back to cited text no. 19
    
20.
Neu A, Willasch A, Ehehalt S, Hub R, Ranke MB; DIARY Group Baden-Wuerttemberg. Ketoacidosis at onset of type 1 diabetes mellitus in children – Frequency and clinical presentation. Pediatr Diabetes 2003;4:77-81.  Back to cited text no. 20
    
21.
Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: The search for diabetes in youth study. Pediatrics 2008;121:e1258-66.  Back to cited text no. 21
    


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