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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 77-81

Prevalence and outcome of hypoglycemia in children attending emergency pediatric unit of a specialist hospital in Nigeria


1 Department of Paediatrics, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
2 Department of Paediatrics, Usmanu Danfodiyo University, Sokoto, Nigeria
3 Department of Medicine, Usmanu Danfodiyo University, Sokoto, Nigeria
4 Department of Paediatrics, Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria

Date of Submission23-Feb-2018
Date of Acceptance31-Jul-2018
Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Abdullahi Musa
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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DOI: 10.4103/smj.smj_12_18

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  Abstract 


Background: Hypoglycemia is a common metabolic problem encountered in pediatric emergency admissions. The absence of clinical symptoms does not preclude the presence of hypoglycemia as presentation may vary from asymptomatic to central nervous system and cardiopulmonary disturbances. If untreated, hypoglycemia can result in permanent neurological damage or even death. Objectives: The objective of the study is to determine the prevalence, associated factors and outcome of hypoglycemia in pediatric emergency admissions at Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria. Materials and Methods: The study was a prospective cross-sectional study involving children aged 1 month–13 years. Blood glucose was determined at admission using Accu-Chek® Active Blood Glucose Meter, and hypoglycemia was defined as blood glucose levels <2.8 mmol/L (<50 mg/dL). Age of the patients, sex, interval of last meal, presenting complaints diagnoses were recorded. Results: A total of 154 children were studied. Thirty (19.5%) were infants and 71 (46.1%) were under-fives. Eighty-seven (56.5%) were males with male to female ratio of 1.3:1. The prevalence of hypoglycemia was 22.1%. The predominant disease conditions the children with hypoglycemia presented with were severe malaria, acute diarrheal disease, and sepsis. The prevalence of hypoglycemia was significantly higher among children whose last meal was 8 h and above before presentation (42.9%). Children who presented with hypoglycemia were significantly more likely to die (odds ratio [OR] =13.3; 95% confidence interval [CI] =4.6–38.7). Among those with hypoglycemia, males were significantly more likely to die (OR = 4.2, 95% CI = 1.0–18.0). Hypoglycemia was significantly associated with mortality in children with severe malaria and pneumonia (P = 0.04 and 0.01, respectively). Conclusion: The prevalence of hypoglycemia is still high in our emergency admissions. It is associated with significant mortality especially among male children and those presenting with severe malaria and pneumonia. We recommend that hypoglycemia sought for and promptly treated in children presenting to emergency to reduce mortality.

Keywords: Children, hypoglycemia, outcome, prevalence


How to cite this article:
Musa A, Ilah BG, Sakajiki AM, Adeniji AO, Yusuf I. Prevalence and outcome of hypoglycemia in children attending emergency pediatric unit of a specialist hospital in Nigeria. Sahel Med J 2019;22:77-81

How to cite this URL:
Musa A, Ilah BG, Sakajiki AM, Adeniji AO, Yusuf I. Prevalence and outcome of hypoglycemia in children attending emergency pediatric unit of a specialist hospital in Nigeria. Sahel Med J [serial online] 2019 [cited 2019 Sep 23];22:77-81. Available from: http://www.smjonline.org/text.asp?2019/22/2/77/260833




  Introduction Top


Hypoglycemia is a common metabolic problem encountered in pediatric emergency admissions. If untreated can result in permanent neurological damage or even death. The incidence of hypoglycemia in children admitted to the pediatric emergency unit is found to be 3.2%–39.0%.[1],[2],[3],[4] Disease severity, young age, and prolonged fasting are the common risk factors for hypoglycemia and its attendant complications. In resource-poor settings like developing countries, hypoglycemia may be aggravated by conditions such as malnutrition, infectious diseases, delay in presentation to hospital, and the use of potentially toxic herbal concoctions.[3],[5],[6]

The absence of clinical symptoms does not preclude the presence of hypoglycemia as presentation may vary from asymptomatic to the central nervous system and cardiopulmonary disturbances depending on the age and severity of the hypoglycemia.[7] This means that reliance on clinical manifestations to detect children with hypoglycemia may result in missing the diagnosis with resultant increase complications such as neurologic damage or even death. Studies have shown that hypoglycemia is a significant predictor of fatal outcome in children with severe acute malnutrition, bacteremia, diarrhea, and severe malaria.[2],[8],[9] This study, therefore, aimed to determine the prevalence, associated factors, and outcome of hypoglycemia in pediatric emergency admissions at Ahmad Sani Yariman Bakura Specialist Hospital (ASYBSH), Gusau, Nigeria.


  Materials and Methods Top


The study was a prospective cross-sectional study conducted at the Children's Emergency Paediatric unit (EPU) of ASYBSH, Gusau, Nigeria. All children aged 1 month–13 years, who were admitted, between September 1, 2015, and December 31, 2015, were consecutively recruited. Patients were excluded if they were confirmed to have diabetes mellitus or have had glucose-containing intravenous fluids within 24 h before admission. Approval (protocol no ASYBSH/SUB/205/VOL 1) was obtained from the Human Research and Ethics Committee of Ahmad Sani Yariman Bakura Specialist Hospital (ASYBSH), Gusau, Nigeria on 3rd August 2015 before the commencement of the study. Informed consent was also obtained from parents or caregivers.

Blood glucose was determined using Accu-Chek® Active Blood Glucose Meter at the bedside, with blood collected by finger prick. Blood glucose results were provided in mmol/L. Hypoglycemia was defined as blood glucose levels <2.8 mmol/L (<50 mg/dL) out of concern for possible adverse neurologic and intellectual sequelae in later life when glucose is <2.8 mmol/L in infants.[10] Hypoglycemia was treated with immediate infusion of intravenous bolus of 2 ml/kg body weight (BW) of 10% glucose water over a minute followed by a continuous dextrose infusion at 8 mg/kg BW/min.[10] Information regarding the age of the patients, sex, interval of the last meal, and presenting complaints diagnoses were collected. The patients' outcomes were recorded as discharged or died.

The data obtained were analyzed using Epi info™statistical software version 3.5.1. (2008). P < 0.05 was considered as statistically significant.


  Results Top


A total of 154 children were seen during the study out of which 30 (19.5%) were infants, 71 (46.1%) under-fives and 11 (7.1%) were adolescents. Eighty-seven (56.5%) were males and the remaining 67 (43.5%) were females giving a male-to-female ratio of 1.3:1 [Table 1].
Table 1: Age and sex distribution of the patients

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[Table 2] shows the various diagnoses of the children studied. Severe malaria was the most common diagnosis and accounted of 29.2% of all the cases followed by acute diarrheal disease with 14.3% and sepsis with 13.6%.
Table 2: Diagnoses of patients with and without hypoglycemia

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Prevalence of hypoglycemia

Of the 154 children, 34 (22.1%) children had hypoglycemia. The leading diagnosis presenting with hypoglycemia were acute diarrheal disease 8 (36.4%), protein-energy malnutrition 4 (28.6%), and severe malaria 11 (24.4%) [Table 2]. By age group, the prevalence of hypoglycemia was higher among children <5 years (26.8%) [Table 3]. The prevalence of hypoglycemia was higher among girls when compared to males, but this was not statistically significant (28.4% versus 17.2%, odds ratio [OR] = 1.9 (95% confidence interval [CI] =0.9–4.1). Those children whose last meal was 8 h and beyond before presentation were significantly more likely to develop hypoglycemia (34.0%) compared to those who had their last meal <8 h before presentation (16.8%) (OR = 2.6, CI = 1.2–5.6) [Table 3].
Table 3: Comparison of characteristics of patient with and without hypoglycemia

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Outcome

Overall 20 patients died giving a mortality rate of 13%. Of the 34 children with hypoglycemia at admission 14 died giving a case fatality rate of 41.2%. Children <5 years of age had 1.3 odds of dying when compared to those above 5 years, although this was not statistically significant. Children who presented with hypoglycemia were significantly more likely to die when compared to those without hypoglycemia (OR = 13.3; 95% CI = 4.6–38.7) [Table 3]. Among those with hypoglycemia males were significantly more likely to die (OR = 4.2, 95% CI = 1.0–18.0) [Table 4]. There was significant mortality when hypoglycemia occurred in children presenting with severe malaria (P = 0.04) and pneumonia (P = 0.01) [Table 5]. Even though it was not statistically significant, hypoglycemia was also associated with mortality in children with acute diarrheal disease, sepsis, malnutrition, and rabies.
Table 4: Outcome of children with hypoglycemia

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Table 5: Comparison of outcome of hypoglycemic and nonhypoglycemic patients with their various diagnoses

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  Discussion Top


In this study, the prevalence of hypoglycemia was 22.1% among children at the admission point at the EPU of ASYBSH, Gusau, Nigeria. This was higher than 5.6% previously reported from Lagos, Nigeria,[4] 3.1% from Madagascar,[5] 18.3% from Benin in Nigeria,[11] and 7.3% from Kenya.[6] The higher prevalence seen in our study compared to the previous studies may be due to differences in the definition of hypoglycemia used and also patients presenting diagnosis. In this study, a higher cutoff of <2.8 mmol/L was used in defining, whereas <2.2–<2.6 mmol/L was used as cutoff in those studies from Nigeria, Kenya, and Madagascar. The prevalence in our study was lower than the 25.5% reported from Katsina.[12] The higher prevalence from Katsina may be because over 80% of the children studied had malaria parasitemia and hypoglycemia is a known complication of malaria that is usually ascribed to increased glucose use and impaired glucose production caused by the inhibition of gluconeogenesis.[13],[14]

There was a significantly higher prevalence of hypoglycemia among children under the age of 5 years. This is comparable to previous studies from Nigeria[4],[15] and Kenya.[6] The higher prevalence of hypoglycemia in under-fives may be because of lower capacity to handle glucose homeostasis in younger children compared with older children and adolescents because of their smaller reserves of liver glycogen and muscle protein and also coupled with their relatively higher rates of glucose utilization due to their greater brain-to-BW ratio.[4],[16]

The Interval between the last feed and blood sampling ≥8 h was significantly associated with a higher prevalence of hypoglycemia. Similar findings were documented in other previous studies.[4],[6],[15] This may be because children are prone to develop hypoglycemia after short fasting as a result of faster rate in the fall of blood glucose and gluconeogenic substrate as characteristic features of fasting adaptation in children.[17] This is further worsened by the defective gluconeogenesis in most childhood illnesses. The prevalence of hypoglycemia was higher in children under 5 years which was similar to findings by other studies from Nigeria.[3],[12],[15] The prevalence of hypoglycemia was also significantly higher in males. This finding was also reported by other previous studies from Nigeria.[12],[15]

There was an increased chance of death in children presenting with hypoglycemia, which was also the finding of researchers in other studies.[3],[4],[11],[15] This may be because hypoglycemia may be a marker for severity of a disease in children and the more severe the illness, the more likely the chances of death which was also asserted by Elusiyan et al.[15] Male children with hypoglycemia were also significantly more likely to die. The reason for this was not clear from the study. Hypoglycemia was also shown to be associated with mortality in severe malaria, acute diarrheal disease, septicemia, and pneumonia. This is similar to other studies from Nigeria[4],[13],[15] and the USA.[18] Even though these disease conditions can be fatal on their own, the association between hypoglycemia and severe malaria and pneumonia was significant despite higher cut off for hypoglycemia in our study. Furthermore, a study from the United States by Mortensen et al.,[18] has reported that after adjusting for severity of illness and other potential confounders hypoglycemia is significantly associated with mortality for patients hospitalized with pneumonia.

Our study is limited by the fact that patients' glucose level was taken only at admission and so those that developed hypoglycemia subsequently have not been captured.


  Conclusion Top


Hypoglycemia in children is a common medical emergency in our hospital with the prevalence of 22.1%. It is associated with significant mortality especially in males, children with prolong fasting and those with severe malaria and pneumonia even at high cutoff limit for hypoglycemia. We, therefore, recommend that children presenting to EPU should be screened for hypoglycemia and promptly treated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Chisti MJ, Ahmed T, Bardhan PK, Salam MA. Evaluation of simple laboratory investigations to predict fatal outcome in infants with severe malnutrition presenting in an urban diarrhoea treatment centre in Bangladesh. Trop Med Int Health 2010;15:1322-5.  Back to cited text no. 2
    
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Madrid L, Acacio S, Nhampossa T, Lanaspa M, Sitoe A, Maculuve SA, et al. Hypoglycemia and risk factors for death in 13 years of pediatric admissions in Mozambique. Am J Trop Med Hyg 2016;94:218-26.  Back to cited text no. 3
    
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Oyenusi EE, Oduwole AO, Oladipo OO, Njokanma OF, Esezobor CI. Hypoglycaemia in children aged 1 month to 10 years admitted to the children s emergency centre of lagos university teaching hospital, Nigeria. SAJCH 2014;8:107-11.  Back to cited text no. 4
    
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Sambany E, Pussard E, Rajaonarivo C, Raobijaona H, Barennes H. Childhood dysglycemia: Prevalence and outcome in a referral hospital. PLoS One 2013;8:e65193.  Back to cited text no. 5
    
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Osier FH, Berkley JA, Ross A, Sanderson F, Mohammed S, Newton CR, et al. Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: Prevalence and outcome. Arch Dis Child 2003;88:621-5.  Back to cited text no. 6
    
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Chisti MJ, Ahmed T, Ashraf H, Faruque AS, Huq S, Hossain MI. Hypoglycemia in children attending the critical care medicine in developing countries. In: Rigobelo EC (ed). Diabetes: Damages and Treatments (vol 2) Rijeka, Croatia: In Tech; 2009. p. 27-46.  Back to cited text no. 7
    
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Huq S, Hossain MI, Malek MA, Faruque AS, Salam MA. Hypoglycaemia in under-five children with diarrhoea. J Trop Pediatr 2007;53:197-2.  Back to cited text no. 8
    
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Marsh K, Forster D, Waruiru C, Mwangi I, Winstanley M, Marsh V, et al. Indicators of life-threatening malaria in African children. N Engl J Med 1995;332:1399-404.  Back to cited text no. 9
    
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Sperling MA. Hypoglycemia. In: Kliengman RM, Berhman RE, Jenson HB, editors. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders Elsevier; 2003. p. 505-17.  Back to cited text no. 10
    
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Onyiriuka AN, Peter OO, Onyiriuka LC, Awaebe PO, Onyiriuka FU. Point-of-admission hypoglycaemia among under-five Nigerian children with plasmodium falciparum malaria: Prevalence and risk factors. Med J Islam Repub Iran 2012;26:78-84.  Back to cited text no. 11
    
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Usman AD, Aishatu YM, Abdullahi B. Laboratory assessment of hypoglycaemia due to malaria in children attending general hospital, Katsina. Bayero J Pure Applied Sci 2008;1:6-9.  Back to cited text no. 12
    
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Thien HV, Kager PA, Sauerwein HP. Hypoglycemia in falciparum malaria: Is fasting an unrecognized and insufficiently emphasized risk factor? Trends Parasitol 2006;22:410-5.  Back to cited text no. 13
    
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Ogetii GN, Akech S, Jemutai J, Boga M, Kivaya E, Fegan G, et al. Hypoglycaemia in severe malaria, clinical associations and relationship to quinine dosage. BMC Infect Dis 2010;10:334.  Back to cited text no. 14
    
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Elusiyan JB, Adejuyigbe EA, Adeodu OO. Hypoglycaemia in a Nigerian paediatric emergency ward. J Trop Pediatr 2006;52:96-102.  Back to cited text no. 15
    
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Sunehag AL, Treuth MS, Toffolo G, Butte NF, Cobelli C, Bier DM, et al. Glucose production, gluconeogenesis, and insulin sensitivity in children and adolescents: An evaluation of their reproducibility. Pediatr Res 2001;50:115-23.  Back to cited text no. 16
    
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Otto Buczkowska E, Szirer G, Jarosz-Chobot P. Glucose homeostasis in children. I. Regulation of blood glucose. Przegl Lek 2001;58:20-4.  Back to cited text no. 17
    
18.
Mortensen EM, Garcia S, Leykum L, Nakashima B, Restrepo MI, Anzueto A, et al. Association of hypoglycemia with mortality for subjects hospitalized with pneumonia. Am J Med Sci 2010;339:239-43.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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