|Year : 2013 | Volume
| Issue : 3 | Page : 97-101
Childhood diabetes mellitus in sokoto, north-western Nigeria: A ten year review
Omoshalewa Ugege, Paul Kehinde Ibitoye, Nma Mohammed Jiya
Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||22-Nov-2013|
Department of Pediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background : There is paucity of literature on childhood diabetes mellitus (DM) from developing countries, especially North-Western Nigeria. We describe the clinical presentation and outcome of childhood DM as seen in Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto, Nigeria. Materials and Methods : This was a 10-year retrospective review of case files of children aged 15 years and below with childhood DM seen between September 1 st 2001 and August 31 st 2011. The age, gender, presenting features, complications, laboratory features, and outcome of the patients were extracted and analyzed. Results: Eight out of the 23,931 children admitted during the study period were diagnosed with type 1 (T1) DM, giving a case prevalence rate of 0.33/1000 (3/10 000). The male-to-female ratio was 1:1. The mean age at presentation was 11.8 ± 3.1 years. The mean duration of symptoms before presentation was 6 ± 4.9 weeks (range 1.2-12 weeks). The most prevalent symptoms were polyuria and weight loss, 7 (87.5%) each, polydipsia, 6 (75%), polyphagia, 5 (62.5%), and weakness, 4 (50%). Five (62.5%) patients presented with diabetes ketoacidosis (DKA). The mean random blood sugar (RBS) was 22.6 ± 12.01 (range 13-49.5) mmol/L. Five (62.5%) patients were discharged while three (37.2%) left against medical advice. Four (80%) of the discharges were lost to follow up. Conclusion: Childhood DM is relatively uncommon in UDUTH, Sokoto. There is a high frequency of DKA, late presentation, and default to follow up. We recommend increased awareness campaigns and health education on childhood DM.
Keywords: Childhood diabetes mellitus, nigeria, outcome, presentation
|How to cite this article:|
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
| Introduction|| |
Type 1 Diabetes Mellitus (T1DM) accounts for the majority of cases of diabetes Mellitus (DM) in children.  It is caused by autoimmune destruction of the insulin-producing β cells of the pancreas.  The destruction may take place over a period of many years.  A large proportion (over 80%) of the β cells are destroyed by the time clinical symptoms appear.  In parallel with the increasing incidence of childhood obesity worldwide, the incidence of type 2 diabetes is also increasing. , This is caused by a relative insulin deficiency resulting from the insulin resistant state of obesity.  A recent report by Uloko et al., from Kano, North-western Nigeria described the occurrence of type 2 Diabetes Mellitus in a 12-year-old Nigerian girl. 
In a lean child presenting with diabetes, the diagnosis of T1DM is presumed unless otherwise proven, whereas in an obese child, differentiating between T1DM and T2DM is essential for rational management.  Features such as significant obesity, presence of acanthosis nigricans, negative islet-cell auto-antibodies, or elevated circulating concentrations of C-peptide are in favor of diagnosis of T2DM. 
Malnutrition related Diabetes mellitus (MRDM) is a rare type of Childhood diabetes associated with long term malnutrition.  There are two subtypes, which are, the fibrocalculus pancreatic diabetes (FCDM) and the protein deficient pancreatic diabetes (PDPD). The FCDM is characterized by a socioeconomic setting of poverty and malnutrition, clinical evidence of malnutrition, age of onset between 10 and 30 years, insulin requirement for control, ketosis resistance and radiologically demonstrable pancreatic calcification, and/or evidence of exocrine pancreatic dysfunction. The PDPD has the same characteristics except that there is the absence of clinical and radiological evidence of pancreatic dysfunction and there is relative resistance to insulin. The use of plain abdominal X-rays to detect pancreatic calculi and abdominal ultrasound for detection of abnormal pancreatic morphology with ductal dilatation is of paramount importance in diagnosis of FCDM. 
There is a large geographical variability in the incidence of T1DM.  In the Western hemisphere, whereas DM is one of the most prevalent chronic diseases in childhood, the incidence of T1DM in developing countries is significantly much less.  There are few articles in the literature reporting the incidence and prevalence of T1DM in Africa ,,,
The few available published works in Africa and other developing countries have raised three major issues related to type 1 DM: Late presentation, under diagnosis (delayed and missed diagnosis), and unavailability of insulin. ,, The frequency of ketoacidosis was relatively high in most series and the commonly recognized symptoms of diabetes were present for a relatively long time before presentation. , The diagnosis may be delayed or missed because of the subtle and misleading symptoms of the disease, , as well as lack of trained man-power especially pediatric endocrinologists, diabetes nurses, and unavailability of established pediatric diabetes clinics.  The unavailability of insulin was attributed to the low purchasing power of insulin by the patients and lack of government support in purchasing and distributing insulin. 
There is paucity of data on the clinical presentation and outcomes of childhood DM in Nigeria and no published data from Sokoto, North-Western Nigeria. This study describes the clinical presentation and management outcomes of childhood DM as seen in Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria.
Usmanu Danfodiyo University Teaching Hospital is located on Hospital road in Sokoto metropolis. It has a 554 bed capacity. It serves two neighboring states: Zamfara, Kebbi, and a contiguous neighboring country Niger Republic. The pediatric Unit has a total bed capacity of 120 and is made up of the emergency ward, the medical ward, outpatient clinic, and special care baby unit. It has an average annual outpatient attendance of 18,816.
| Materials and Methods|| |
The study was carried out in Sokoto which is located in the North Western geographical zone of Nigeria with a population of 3.69 million people and the annual growth rate of 3% as at 2006 with a projected population of 4.35 million in 2012.  Most of the ethnic groups are represented but majority are the indigenous population - Hausa/Fulanis. The State is basically agrarian.
This was a 10-year retrospective review of case files of children aged 15 years and below with a final diagnosis of DM, made between September 1 st 2001 and August 31 st 2011. Fifteen years is the cut-off age used as a policy in the pediatrics unit of our hospital. The total number of pediatric admissions during the study period was obtained from the ward register while the case files of children diagnosed with DM were retrieved from the medical records library. Outpatient register did not reveal any child with DM on follow up during the period of review. The age, weight, height, gender, presenting features, complications, laboratory features, and outcome of the patients were extracted from the case files and analyzed.
The diagnosis of DM was based on a single random blood sugar (RBS) ≥11.1 mmol/l in conjunction with typical symptoms of diabetes (polydipsia, polyuria, and polyphagia) or RBS ≥11.1 mmol/l on two separate occasions with or without symptoms  The attempts at identifying T2DM were difficult because there was no documentation of acanthosis nigricans, absent autoantibodies, and elevated circulating C-peptide concentrations. Key issues in management of these children (such as frequency of blood sugar monitoring, blood sugar control, and duration of admission) and the peculiarities of the children with DKA (nutritional status, the age, the rate of signing against medical advice (SAMA) were identified. Using the body mass index (BMI)-for-age (kg/m 2 ), underweight was defined as BMI-for-age <5 th percentile of National Centre for Health Statistics (NCHS) reference standard, Normal weight as 5 th -85 th percentile, overweight >85 th -95 th percentile, and obesity >95 th percentile. 
Data are presented as mean, standard deviation, and range.
| Results|| |
The total number of pediatric admissions into the hospital during the study period were 23°931. Eight out of these patients were diagnosed with T1DM giving a case prevalence rate of 0.33/1000 (or 3/10,000).
[Table 1] show the age and sex distribution of patients. The male-to-female ratio was 1:1. The mean age (±SD) at presentation was 11.8 (±3.1) years. No patient was less than 8 years while 75% of patients were aged more than 8 years.
The duration of symptoms was 12 weeks in 3 (37.5%) patients, 4 weeks in 2 (25%), 2 weeks in 2 (25%), and 1.2 weeks in 1 (12.5%) patient. The mean duration was 6.2 ± 4.9 weeks with the range of (1.2-12 weeks).
The weight, height, and BMI on admission ranged from 19.7-52 kg, 1.26-1.67 m, and 12.0-18.8 kg/m 2 , respectively. Six (75%) of the children were underweight while two (25%) had normal weight for age on admission. No child was overweight or obese.
The most prevalent presenting features were polyuria 7 (87.5%), weight loss 7 (87.5%), polydipsia, 6 (75%), polyphagia 5 (62.5%), and weakness 4 (50%). The other presenting features were abdominal pain, 3 (37.5%)(recurrent in 2 (66.7%) and recent in 1 (33.3%) patient), vomiting, 2 (25%), respiratory distress, 2 (25%), abdominal swelling, 1 (12.5%), Convulsion, 1 (12.5%), fever, 1 (12.5%), and Coma, 1 (12.5%). One patient (12.5%) had hyperglycemia detected accidentally without typical symptoms.
Five (62.5%) patients were presented with diabetic ketoacidosis (DKA). Of these, three (60%) were males and two (40%) were females. Four patients (50%) were referred from a peripheral hospital, three (37.5%) of which were managed by adult physicians while four presented directly to the pediatric clinic. One patient each (12.5%) had malaria and severe anemia, while three patients (37.5%) had sepsis including multiple abscesses.
[Table 2] highlights the mean distribution of blood sugar results and duration of hospital stay. Intravenous rehydration with normal saline was given to 5 (62.5%) of the patients. Only 3 of the patients could measure their blood glucose at least twice a day. The number of times blood sugar was measured in the patients ranged from 1 to 3 times. This was attributed to the lack of glucometer and/or strips, dependence on laboratory results which were frequently missing in transit, and the cost of the tests. All the patients had insulin therapy (four had intravenous infusion and one had intramuscular injection of regular short acting insulin during the acute phase management of DKA). All were put on subcutaneous regular insulin during the maintenance phase.
The most frequent complications were DKA in five (62.5%), hypoglycemia during treatment in two (25%), and nephropathy in two (25%). Five patients (62.5%) were discharged while three (37.5%) signed and left against medical advice (SAMA). None of the children with hypoglycemia were signed against medical advice whereas three (60%) of those that presented with DKA were signed against medical advice. One of the discharged patients (12.5%) was followed up for 2.4 years while the other four (80%) were lost to follow up within 7 months of discharge from hospital. There was no record of hospital death.
| Discussion|| |
In this study, the prevalence of childhood DM in UDUTH is 0.33/1000 (or 3/10 000) which is lower than 3.1/1000 reported by Adeleke et al., in a similar hospital based study in Kano, North western, Nigeria. This finding may not be representative of the population prevalence on account of this being a hospital-based retrospective data. The diagnosis of DM may have been missed in the hospital or the children may have already died before they reached the hospital. Our finding is however similar to that of 0.33/1000 reported by Afoke et al.,  among Igbo children in a population based study at Ishielu and 0.1/1000 by Ibekwe et al.,  In an hospital based study in Abakaliki both in Southeast Nigeria. Though the prevalence rates of childhood DM reported in Nigeria are low, they are higher than those reported from other African countries such as Tanzania  (1.5/100,000). It has been postulated that these low prevalence rate in Africa could be due to lower frequencies of human leukocyte antigen (HLA) DR3, DR4, Islet cell antibodies, and other auto antibodies in the black race. , Other contributory factors could be the high mortality amongst African children with T1DM. 
Equal gender distribution in the prevalence of childhood DM has been documented by some researchers in some African countries such as Tanzania  and Tunisia  which is similar to our finding. Female preponderance, however, was reported by some other African researchers in Nigeria, South Africa, and Ethiopia ,,,, while a group of others in Nigeria and Ethiopia reported male preponderance. ,,,, The reason for this gender variation is not clear, but may be linked to the wide geographical and ethnic variations in the incidence of the disease. 
The mean age at presentation of 11.8 ± 3.1 years found in this study is similar to 11.4 years reported by Ibekwe et al.,  and 10 ± 4.5 years by Adeleke et al. Previous works done have shown the increasing prevalence of type 1 DM with the increasing age. , This was also demonstrated in this study, as 75% of our patients were aged more than 8 years. In fact, Bella et al.,  documented that type 1 DM is rare in children less than 10 years. Karvonen et al.,  in a worldwide survey, documented highest incidence in children aged between 10 and 14 years. In contrast, however, a study from Almadina region of Saudi Arabia  reported a mean age at presentation of 6.9 years.
Majority of the patients presented late as almost two-third of them delayed more than 4 weeks before presentation in hospital. These late presentations could be attributed to the unawareness of symptoms of T1DM by the parents and patients especially the adolescents, or to the subtle nature of the symptoms, on a background of traditional beliefs about the causes of diseases. It may also explain the high rate of DKA seen in this study. Other African studies have also reported the late presentations. ,
The most common presenting symptoms were polyuria, weight loss, polydipsia, and polyphagia. This is consistent with previous studies in Nigeria, , and Saudi Arabia.  However, patients frequently had co-morbid conditions such as malaria, severe anemia, and sepsis as was also reported by Adeleke et al.
Management of these patients was sub-optimal, evidenced by the slow rate of achieving glycemic control, the prolonged hospital stay, the high rate of development of complications, and inadequate blood glucose monitoring. The non-availability of trained pediatric endocrinologists, nurses, and specialized diabetes clinics in our center might have contributed to the sub-optimal management. During the study period, there were no established protocols on management of DKA and T1DM.
There was a high rate of discharge against medical advice and default to follow up, which may be due to frustration, financial constraints, inadequate parent/patient education, underlying poverty, and poor standard of care. These have been previously highlighted by Ibekwe et al. Though there was no record of hospital death in this study, some of these patients may have died at home in view of the high rate of SAMA and default to follow up.
| Conclusion|| |
The findings in our study have shown that childhood DM is relatively uncommon in UDUTH, Sokoto; they were presented with classical symptoms of diabetes, the frequency of DKA, and default to follow up was high.
We recommend awareness campaign and health education aimed at early recognition of symptoms of diabetes by parents. There is need for improvement in the management of childhood diabetes through manpower development and provision of facilities.
We were constrained by lack of facilities to determine the C-peptide and auto-antibodies concentrations in our patients.
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[Table 1], [Table 2]
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