Clinical profile of diabetes at diagnosis among children and adolescents at an endocrine clinic in Ghana

Abstract

AIMTo determine the clinical features of diabetes in children and adolescents in Ghana.METHODSRetrospective review of clinical features of all children and adolescents with new-onset diabetes seen at the paediatric endocrinology clinic of Komfo Anokye Teaching Hospital in Kumasi, from February 2012 to Auguest 2016.RESULTSOne hundred and six subjects presented with diabetes. Ninety (84.9%) were diagnosed by clinical features and family history as type 1, and 16 (15.1%) type 2. For type 1 subjects, age range at diagnosis was 0.9-19.9 year (y), peak age of onset 12-13 year, and 3.3% were < 5 year, 21.1% 5- < 10 year, 45.6% 10- < 15 year and 30.0% 15- < 20 year. Seventy-one point one percent were female. Common clinical features were polyuria (100%), polydipsia (98.9%), and weight loss (82.2%). Mean BMI SD was -0.54, range -3.84 to 2.47. 60.0% presented in diabetic ketoacidosis (DKA). Nine had infections at onset (skin, abscess, leg ulcer). Mean ± SD HbA1c at diagnosis was 12.7% ± 1.9% (115 ± 21 mmol/mol). Four have since died: Hypoglycaemia (2), recurrent DKA (1), osteosarcoma (1). Two other type 1 cases died of DKA at presentation in emergency before being seen by the paediatric endocrinologist. Crude mortality rate including these 2 cases was 32.2/1000 patient years. Type 2 cases were 81% female, age of onset 9-19 year. Mean BMI SD was 1.49, range -0.87 to 2.61. Forty-three point eight percent presented in DKA. All type 2 cases had acanthosis nigricans. Overall, 9.8% did not have home refrigeration, most using clay pot evaporative cooling for insulin storage.CONCLUSIONType 1 occurs with a female preponderance and high DKA rates. Type 2 also occurs. Typology based on clinical features is difficult. Community and professional awareness is warranted.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels

“…Mortality rates fall sharply as care (including management of diabetic ketoacidosis) begins to improve, and thus prevalence increases …”

“…35,36 Although analog insulin is almost universally preferred over human insulin by health care professionals and people with type 1 in well-resourced countries, it is important to note that, despite many studies, improvements in HbA1c levels have not been showed. 32,35,336 It is accepted that analog insulin helps to reduce rates of nocturnal hypoglycemia in well-resourced settings. 32,35,37 Therefore, when funds are limited, it is much more important to have more frequent SMBG rather than analog insulin.…”

Insights from the WHO and National Lists of Essential Medicines: Focus on Pediatric Diabetes Care in Africa

“…The national EML for Ghana includes short-acting, intermediate-acting and premixed human insulins as well as analogue insulins and glucagon [16]. However, only short- and intermediate-acting human insulins are (irregularly) available through the NHIS [13]. The cost of a vial of insulin (1,000 units) varies from 0 USD (insured patient when insulin is available at the hospital pharmacy) to 7 USD (insured patient who buys the insulin from a nonhospital pharmacy) and 15 USD (nonsubsidized price).…”

“…Mortality and morbidity is likely underreported because clinical features of pediatric endocrine diseases and of diabetes may mimic infections and other common medical conditions, causing misdiagnosis [39, 40]. In addition, a complete neonatal examination is not routinely performed in many settings, preventing the diagnosis of congenital conditions such as disorders of sexual development [13, 41]. It is expected that the increase in capacity in pediatric endocrinology will lead to a better understanding of the prevalence and characteristics of pediatric endocrine diseases and diabetes which, in turn, will drive advocacy for essential medicines that are presently not available to the patient.…”

“…The PETCA program has also led to the foundation in 2009 of the African Society for Paediatric and Adolescent Endocrinology (ASPAE), which aims at promoting “the highest levels of knowledge, research, education and clinical practice of paediatric endocrinology and metabolism throughout Africa” [10]. While these initiatives have contributed to a marked increase in the number of children appropriately diagnosed with endocrine conditions and diabetes in Africa [11-13], they have also shed light on the regional difficulties faced by patients and physicians in accessing the medicines needed to treat these conditions.…”