ORIGINAL

Niger J Paed 2013; 40 (4): 384 –388

Onyiriuka AN

Awaebe PO

Kouyaté M

Hypoglycaemia at point of hospital

admission of under-five children

with acute diarrhoea: prevalence

and risk factors

DOI:http://dx.doi.org/10.4314/njp.v40i4,7

Accepted: 18th April 2013

Abstract Background: Hypogly-

caemia is one of life-threatening

immediate complications of acute

diarrhoea among under-five chil-

dren but its diagnosis may be

overlooked because all the symp-

toms may be mimicked by severe

dehydration.

Objective: To determine the

prevalence of hypoglycaemia at

the point of hospital admission of

under-five children with acute

diarrhoea and identify some of the

risk factors.

Methods: At the point of hospital

admission, venous blood sample

was collected into an appropriate

sample bottle (fluoride-oxalate

bottle) from 201 under-five chil-

dren with acute diarrhoea for

blood glucose determination. The

blood samples were analysed

using the glucose-oxidase method.

One of the authors administered a

questionnaire to each of the care-

giver to obtain information on the

socio-demographic characteristics

and the clinical profile (e.g., pres-

ence or absence of vomiting, du-

ration of acute diarrhoea, time of

last meal of the patients, and ad-

ministration of ORS at home.

Hypoglycaemia was defined as

blood glucose value below 2.6

mmol/L.

admission, 7.7% (14 of 183; CI =

3.7-11.7) under-five children with

acute diarrhoea had hypoglycae-

mia (blood glucose < 2.6 mmol/L)

but dropped to 4.9% (CI=2.9-6.9)

when a cutoff point of < 2.2 mmol/

L was applied. The risk factors for

hypoglycaemia were the presence

of severe dehydration (p<0.001),

hypernatraemia and acidosis

(p<0.001). The prevalence of

hypoglycaemia was 7 times higher

in children whose time of last meal

was ≥ 8 hours compared with their

counterparts whose time of last

meal was < 8 hours. Mortality rate

was significantly higher in chil-

dren with acute diarrhoea and hy-

poglycaemia compared with their

counterparts with normoglycaemia

(p<0.01).

(

)

Onyiriuka AN

Department of Child Health,

University of Benin Teaching Hospital,

PMB 1111,

Benin City, Nigeria.

E-mail: alpndiony@yahoo.com

didiruka@gmail.com

Awaebe PO

Medical Laboratory Unit,

St Philomena Catholic Hospital,

Benin City, Nigeria

Kouyaté M

Service de Pédiatrie,

Unité d’endocrinologie pédiatrique

Hôpital National de Donka,

CHU de Conakry, Guinea.

Conclusion: In acute diarrhea,

hypoglycaemia is an important co-

morbidity among children aged

below 36 months and the signifi-

cant associated risk factors for

hypoglycaemia are severe dehy-

dration,

hypernatraemia and

acidosis. Under-five children pre-

senting with acute diarrhoea and

hypoglycaemia at point of hospi-

talization are at a significantly

greater risk of death.

Key words: Acute diarrhoea, hy-

Results: At the point of hospital

poglycaemia, hypernatraemia,

Introduction

been clearly established as the immediate life-

threatening complications of acute diarrhoea, a

Acute diarrhoea refers to diarrhoea of sudden onset

non-dehydrating c₄o_-₇mplication like hypoglycaemia is

(

generally, ov₁er hours rather than days), lasting for less

equally important.

Even in areas where oral rehydra-

than 14 days. In developing countries, diarrhoeal dis-

eases is a leading cause of morbidity and mortality

among under-five children with an average of 3.3 epi-₂

sodes of diarrhoea being experienced per child per year.

Acute diarrhoea is associat₃ed with a high mortality rate

among under-five children.

tion therapy is being practised, mortality from acute

8

diarrhoea still remains high, suggesting that other

factors may be playing a role in the observed mortality

rates. In Africa, there is limited data on hypoglycaemia

as one of the clinical problems encounte₉red in the man-

agement of children with acute diarrhea. This scenario

might be related to the fact that the symptoms of severe

Although dehydration and electrolyte derangement have

3

85

dehydration and hypoglycaemia resemble each other,

resulting in difficulty in_-d₆ ifferentiating between these

tients. It has a fairly well equipped laboratory manned

by qualified medical laboratory scientists and offers a 24

-hour laboratory service.

4

two clinical conditions . The co-existence of severe

dehydration and hypoglycaemia in patients with acute

4

,5,7

diarrhorea has been shown to worsen prognosis ,

At the point of admission, all children between the age

of one and 59 months who presented with acute diar-

rhoea were recruited into the study after explaining the

relevant details of the study to their parents/caregivers

and obtaining their consent subsequently. The study

design was approved by the hospital authority. Follow-

ing recruitment, pretreatment venous blood sample was

obtained from each of the patients for blood glucose

estimation. The blood sample was collected into the

appropriate sample containers (dry fluoride-oxalate bot-

tles) and forwarded immediately to the hospital labora-

tory for processing. The blood glucose concentration

was d₁e₄termined using glucose-oxidase reaction

The urea and electrolyte profile of the pa-

tients was also determined. Based on the serum sodium

level, the type of dehydration was categorized as hypo-

natraemic (serum sodium < 130 mmol/L); normonatrae-

mia (serum sodium 130-150 mmol/L); and hypernatrae-

mia (serum sodium > 150 mmol). Two medical labora-

tory scientists (with over 20 years experience) processed

the samples urgently at the request of the admitting

physician and the average of the two plasma glucose

values obtained was accepted. A blood film for malaria

parasitaemia was performed. Inclusion criteria were age

below 60 months, Nigerian, negative malaria parasitae-

mia, absence of overt protein-energy malnutrition

(kwashiorkor/marasmus), negative history of treatment

with quinine and/or herbal concoctions. Subjects with a

coexisting morbidity (e.g., malaria, pneumonia) that are

known to cause hypoglycaemia were excluded. A struc-

tured questionnaire was administered to the caregiver of

each of the patients by one of the authors (ANO). Infor-

mation obtained included socio-demographic character-

istics such as age, gender, parents’ educational attain-

ment and occupation. Data were also obtained on history

of duration of diarrhoea, presence of vomiting or fever,

time of last meal.

implying that early detection and adequate treatment of

the hypoglycaemia in such patients might improve out-

come. Hypoglycaemia is a common clinical problem

and it is associated with serious neurological sequelae

when detection is delayed or treatment inadequate. Even

though low blood glucose may often be transient, hypo-

glycaemia itself is never phy₀siological and should not be

1

disregarded when detected. Some risk factors that have

been identified include female gender, seizure, altered

level of consciousness, vomiting, acidosis, d₄u_,₇r_,₁a₁tion of

diarrhoea less than 72 hours, and bacteraemia.

A review of the literature revealed that the prevalence of

hypoglycaemia in₄_-₆children with acute diarrhoea varied

from 4.5-11.0%. This variability in prevalence rates

have been obs₄e_,r₆ved at different times, even within the

same country . In a study in Calabar, Nigeria, 4.0% of

under-five children presenting₇with acute diarrhoea were

found to have hypoglycaemia. A study in a rural dis-

trict hospital in Kenya, reported a prevalence of hypo-

glycaemia as high as 23.3% among children₂ with acute

method.

1

diarrhoea at the point of hospital admission. All previ-

ous Nigerian studies on this subject were conducted in

tertiary-healthcare hospitals and none in secondary-

healthcare hospital, yet a significant number of children

are cared for in secondary-healthcare facilities. Consid-

ering that in developing countries, childhood diarrhoea

7

itself is gro₃ssly under-reported and its incidence under-

1

estimated, the magnitude of the paucity of information

on hypoglycaemia coexisting with diarrhoea becomes

more obvious. At present, in Nigeria, the extent to

which hypoglycaemia occur in children with diarrhoea is

uncertain. We are not aware of any study in Benin City

that has determined the prevalence of hypoglycaemia or

examined its risk factors among under-five children with

acute diarrhoea. The factors highlighted above prompted

us to conduct the present study.

The severity of dehydration was determined for each

patient by physical examination. In the present study,

hypoglycaemia was defined as blood glucose value be-

low 2.6 mmol/L while hyperglycaemia was d₀efined as

The purpose of the present study was to determine the

prevalence of hypoglycaemia at the point of hospital

admission of under-five children with acute diarrhoea in

Benin City and identify some of the risk factors. Hope-

fully, such information would be useful to clinicians in

developing appropriate protocol for management of chil-

dren hospitalized for acute diarrhoea, thereby improving

outcome.

1

blood glucose value greater than 8.3 mmol/L. All the

children found to have hypoglycaemia were treated with

10% dextrose in water at 4ml/kg/hour. No treatment

was given to the two children with hyperglycaemia. At-

tention was equally paid to their fluid and electrolyte

status with treatment as determined by the child’s clini-

cal condition. The data was analyzed using the Com-

puter Package for Epidemiologist (PEPI). Descriptive

statistics such as frequencies, means, ratios, standard

deviations, confidence intervals, percentages were used

to describe all the variables. The Z-test was used in as-

certaining the significance of differences between two

proportions with the p-value set at <0.05.

Patients and methods

This descriptive cross-sectional study was conducted

between January and December, 2010 at St Philomena

Catholic Hospital (SPCH), Benin City, Nigeria. SPCH is

a centrally located, easily accessible large secondary-

healthcare institution that cares for all categories of pa-

3

86

Results

Table 2: Prevalence of hypoglycaemia stratified by age and

gender

During the twelve-month study period, a total of 230

under-five children were admitted for acute diarrhoea.

Of this number, 37 (16.1%) had a positive malaria para-

sitaemia and were excluded because malaria, itself, is an

established cause of hypoglycaemia. Ten (4.3%) moth-

ers declined to participate in the study, leaving 183 pa-

tients whose data analysis is presented. The 183 patients

consisted of 99(54.1%) males and 84(45.9%) females,

giving a male-to-female ratio of 1.2:1. At the point of

hospital admission, 7.7% (14 of 183; 95%CI 3.7-11.7)

had hypogycaemia (blood glucose < 2.6 mmol/L),

When a cutoff point of < 2.2 mmol/L was applied, the

prevalence dropped to 4.9% (9 of 183); 95% CI = 2.9-

Age (months) Subjects Hypogly Normogly

Z-statistic

(p-value)

caemia

No (%)

caemia*

No (%)

a

<

12

81(44.3) 7(8.6) 74(91.4) a vs b= 3.212 (p<0.01)

63(34.4) 5(7.9) 57(91.9) b vs c=0.847 (p>0.05)

39(21.3) 2(5.1) 36(92.3) a vs c=0.614 (p>0.05)

183(100.0) 14(7.7) 165(90.2)

b

c

12-35

6-59

Total

3

Gender

Male

Female

Total

99(54.1) 8(8.1) 90(90.9) Odd Ratio 1.1

84(45.9) 6(7.1) 77(91.7)

183(100.0) 14(7.7) 167(91.3)

*Two subjects had hyperglycaemia

As depicted in Table2, 12(85.7%) of 14 children with

hypoglycaemia were below 36 months of age. Only two

6

.9). Two (1.1%) of 183 under-fives with acute diar-

rhoea had hyperglycaemia. Comparing the age preva-

lence of hypoglycaemia among children aged below 36

months and their counterparts aged between 36-59

months, it was 8.3% versus 5.1% respectively; Z-

statistic = 0.761 p>0.05. The mean age of the subjects

was 14.6±10.5 months (95% CI= 13.1-16.1). Vomiting

accompanied diarrhoea in over half of the cases (Table

(

1

14.3%) were aged 36 to 59 months. Nine (64.3%) of

4 children with hypoglycaemia had acidosis. The dura-

tion of diarrhoeal illness before presentation did not sig-

nificantly influence the prevalence of hypoglycemia.

Table 3 shows that the risk of hypoglycaemia was seven

times higher when the time of last meal was ≥ 8 hours

compared to when it is < 8 hours. Children with severe

dehydration were at a significantly greater risk of hypo-

glycaemia than their counterparts with a lower degree of

dehydration (Table 4).

1

). The mean electrolyte values are shown in Table 1.

The distribution of type of dehydration (based on serum

sodium concentration) among the study population was

as follows: hyponatraemic dehydration 58.5% (107 of

1

83), isonatraemic dehydration 36.6% (67 of 183) and

hypernatraemic dehydration 4.9% (9 of 183). Seven

77.8%) of 9 cases of hypernatraemia had acidosis and

Table 3: Prevalence of hypoglycaemia according to time of last meal

(

Time of

last meal

Subjects Hypoglycaemia Normoglycaemia* Odd Ratio

hypoglycaemia.

No (%)

No(%)

<

≥

8 hours 118(64.5) 8(6.8)

109(92.4)

58(89.2)

7.2

8 hours 65(35.5)

6(9.2)

Table 1: Characteristics of the 183 children with acute

diarrhoea.

Total

183(100.0) 14(7.7)

167(91.3)

Parameter

Number

%

*Two subjects had hyperglycaemia

Duration of diarrhoea < 3 days*

Duration of diarrhoea ≥3 days

Vomiting present

Vomiting absence

Fever present

Fever absent

Used ORS at home

Did not use ORS at home

101

82

96

87

85

98

100

83

Mean±SD (95% CI)

130.2±7.4 (129.1-131.3)

3.1±0.8 (3.0-3.2)

98.4±8.5 (97.2-99.6)

13.5±4.4 (12.9 -14.1)

27.1±16.8 (24.7-29.5)

55.2

44.8

52.5

47.5

46.4

53.6

54.6

45.4

Table 4: Prevalence of hypoglycaemia according to hydration

status

Hydration status

Total

Hypogly Normogly Z-statistic

caemia caemia * (p-value)

No (%)

Mild dehydration

46(25.1) 0(0.0) 45 (97.8)

a

Moderate dehydration 118(64.5_b) 5(4.2) 112(94.9) a vs b =3.723

Severe dehydration 19(10.4) 9(47.4) 10(52.6) (0.001)

Total 183(100.0) 14(7.7) 169(92.3)

Mean serum sodium (mmol/L)

Mean serum potassium (mmol/L)

Mean serum chloride (mmol/L)

Mean serum bicarbonate (mmol/L)

Mean serum urea (mg/dl)

*Two subjects had hyperglycaemia

As shown in Table 5, the commonest type of dehydra-

tion was hyponatraemic dehydration while hypernatrae-

mic dehydration was the form of dehydration most com-

monly associated with hypoglycaemia. A total of eight

of 183 children died, representing a case fatality rate

*Before presentation

4

.4%. Five (62.5%) of the eight had hypoglyaemia.

None of the two subjects with hyperglycaemia died.

When mortality rate between the hypoglycaemic group

was compared with the normoglycaemic group, it was

3

5.7% (5/14) versus 1.8% (3/169); Z-statistic = 2.627

p<0.01. Three of the five children with hypoglycaemia

who died, also had hypernatraemia and acidosis. The

remaining two hypoglycaemic children who died had a

combination of hyponatraemia and acidosis. Of the

3

87

normoglycaemic children who died, two had severe hy-

ponatraemia with acidosis and one had hypernatraemia

with acidosis. In this series, it is of note that acidosis

was a common factor among all the deaths.

glycaemia whereas the substrates for gluconeogenesis

were inappropriately low in them, leading to the conclu-

sion that hypoglycaemia in such children was most

likely due to impaired hepatic gluconeogenesis. The

report of another study also linked hypoglycaemia asso-

ciated diarrhoeal illnesses in children to glyco₁g₉en de-

Table 5: Prevalence of hypoglycaemia according to type of

dehydration

pletion and impaired hepatic gluconeogenesis.

The

higher risk of hypoglycaemia observed in the present

study among under-five children with diarrhoea in

whom the time of last meal was 8 hours and above is in

tandem with glycogen depletion as one of the pathoge-

netic mechanisms of hypoglycaemia in diarrhoeal

illnesses.

Type of

dehydration

Subjects Hypogly Normogly

caemia caemia *

No (%) No (%) No (%)

Z-statistic

(p-value)

a

Hyponatraemic 107(58.5) 5(4.7) 101(94.4) a vs b=0.582(p>0.05)

b

67(36.6) 2 (3.0) 64(95.5) b vs c = 1.996 (p<0.05)

c

Isonatraemic

Hypernatraemic 9(4.9) 7 (77.8) 2(22.2) a vs c = 5.220 (p<0.001)

Total 183(100.0) 14(7.7) 169(92.3)

Hyperglycaemia was present in one out of every hun-

dred patient in the present study. There was no mention

of the occurrence of hyperglycaemia in the study in

*Two subjects had hyperglycaemia

7

Calabar, making it impossible to judge whether or not

any of their subjects had hyperglycaemia. A₂ study in

1

Kenya has reported a similar observation. In that

Discussion

study, 12.9% of 96 children with hyperglycaemia had

gastroenteritis as their diagnosis, representing a preva-

lence of 3.7%. The prevalence of hyperglycaemia was

higher in the Kenyan study than in the present one

In the present study, the prevalence of hypoglycaemia at

the point of hospital admission of under-five children

presenting with acute diarrhoea was 7.7%. This was

higher than the 4.0% and 4.5% r₁e₅ported from Calabar,

despite the fact that they used a higher cut-off value of >

1

0 mmol/L. The reason for this difference is not clear.

7

Nigeria and Dhakar, Bangladesh respectively. On the

In contrast to the Kenyan study, none of the two patients

with hyperglycaemia died.

other hand, the prevalence being reported here is lower

than 11.0% reported from another study₄in Bangladesh

among under-five diarrhoeal children. The higher

prevalence rate observed in the present study compared

to the previous study in Calabar may be explained by the

differences in definition of hypoglycaemia used in the

two studies. In the present study, a higher cut-off (<2.6

mmol/L, based on the concept of operational threshold

Data from the present study revealed that among under

-

five children with acute diarrhoea, severe dehydration,

hypernatraemia and acidosis were significant risk fac-

tors for hypoglycaemia. This is not surpri₇s_,₁i₅ng as similar

observation has been reported previously.

The severe

dehydration and acidosis may impair the function of

various enzymes involved in gluconeogen₁e₅sis as well as

interfere with the transport of substrates. However, in

1

6

blood glucose values ) was used in defining hypogly-

caemia whereas < 2.2 mmol/L was used as cut-off in the

Calabar study, partly accounting for the higher preva-

lence observed in the present study. The definition of

hypoglycaem₇ia used in a study is known to influence its

7

contrast, Ntia et al did not find any relationship be-

tween the frequency of hypoglycaemia and serum elec-

trolyte profile. Given the fact that they did not document

in their results, the serum electrolyte profile of their pa-

tients, it is possible they did not focus on electrolytes in

relation to hypoglycaemia. However, in that report, they

did state that five of the six children with hypoglycae-

mia in their series had metabolic acidosis, supporting,

albeit indirectly, the significant association between

acidosis and frequency of hypoglycaemia observed in

the present study.

1

prevalence. This was amply demonstrated in the

present study because when a cut-off of less than 2.2

mmol/L was applied it resulted in a lower prevalence

rate (4.9%). The explanation for the higher prevalence

rate in the present study compared to the prevalence rate

(

4.5%) observed in the study in Bangladesh may be due

to differences in the age group of the study population.

The present study involved o₅nly under-five children

1

whereas the Bangladesh study included children up to

the age of 15 years. Studies have shown that the risk of

hypoglycaemia is high₁e₈r in under-five children com-

pared to older children.

What is the clinical implication of these findings? Case

management efforts in childhood diarrhoeal illnesses

usually focus on correction of fluid and electrolyte

derangement. Clinicians need, in addition, to consider

the role of non-dehydrating complication like hypogly-

caemia in causing death in children presenting with diar-

rhoea. Thus, it might be beneficial for clinicians to

consider the possibility of hypoglycaemia when devel-

oping appropriate protocol for management of children

hospitalized for acute diarrhoea, thereby reducing the

already high mortality associated with childhood diar-

rhoeal illnesses in developing countries. After treatment

of shock, the use of dextrose-containing intravenous

On the other hand, the lower prevalence rate (7.7%)

observed in the present study compared with 11.0%

found in the study by Huq et al may be explained by

4

selection bias. In that study, they investigated only those

children suspected to have hypoglycaemia. The mecha-

nism by which diarrhoea predisposes to hypogly₅caemia

1

is poorly understood. However, Bennish et al, linked

it to defective gluconeogenesis. In that study, they

observed that the glucose counterregulatory hormones

were appropriately elevated in the children with hypo-

3

88

solution in hospitalized children requiring parenteral

fluid therapy is advocated, particularly where facilities

for determination of blood glucose level is not available.

All children presenting with diarrhoea and acidotic

breathing should, in addition to correcting the acidosis,

treated empirically for hypoglycaemia.

and the significant associated risk factors are severe

dehydration, hypernatraemia and acidosis. Routine

assessment of blood glucose at the point of hospital ad-

mission is advocated and where facility for determina-

tion of blood glucose level is not available, treat empiri-

cally for hypoglycaemia to improve outcome.

Conflict of interest: None

Funding: None

Conclusion

Hypoglycaemia is an important co-morbidity of acute

diarrhoea among children below the age of 36 months

References

8

.

Rousmans C, Bennish ML,

15. Bennish ML, Azad AK, Rahman

O, Phillips RE. Hypoglycaemia

during diarrhea in childhood:

prevalence, pathophysiology and

outcome. New Engl J Med 1990;

322(19):1357-1363.

16. Hay WW Jr, Raju TN, Higgins

RD, Kalhan SC, Devaskar SU.

Knowledge gaps and research

needs for understanding and treat-

ing neonatal hypoglycemia: work-

shop report from Eunice Kennedy

Shriver National Institute of Child

Health and Human Development. J

Pediatr 2009;155(5):612-617

17. Williams AF. Hypoglycaemia in

the newborn: a review. Bull World

Health Organ 1997; 75(3): 261-

290.

18. Solomon T, Felix JM, Samuel M,

Dengo GA, Saddanba RA,

Schapira A, Phillips RE. Hypogly-

caemia in paediatric admissions in

Mozambique. Lancet 1994; 343:

149-150.

19. Butler T, Arnold M, Islam M. De-

pletion of hepatic glycogen in the

hypoglycaemia of fatal childhood

diarrhoeal illnesses. Trans Royal

Soc Trop Med Hyg 1989;83(6):839

-843.

1

.

Cutting WAM. Diarrhoeal dis-

eases. In: Stanfield P, Brueton M,

Chan M, Parkin M, Waterson T

eds. Diseases of Children in the

Subtropics and Tropics, 4 ed.

London Arnold Publishers,

Weizba T. Diagnosis and manage-

ment of dysentery by community

health workers. Lancet 1988;2:552

-555.

Lee LA, Dogore R, Redd SC,

Dogore B, Metchock B, Diabate J,

van Assendelft OW, DeCock K,

Patrick E, Herrington J. Severe

illness in African children with

diarrhea: implications for case

management strategies. Bull World

Health Org 1995;73(6):779-785.

th

9

.

1

991:455-495.

2

3

.

Patwari AK. Diarrhoeal diseases.

In: Parthasarathy A ed. IAP Text-

th

book of Pediatrics 4 ed. Vol 1,

New Delhi, Jaypee Brothers Medi-

cal Publishers 2009:602-608.

Synder JD, Merson MH. The mag-

nitude of the global problem of

acute diarrhoeal disease: a review

of active surveillance data. Bull

World Health Org 1982;60(4):605

1

0. Ferry RJ Jr, Allen DB. Hypoglyce-

mia. In: Kappy MS, Allen DB,

Geffner ME. Pediatric Practice:

Endocrinology. New York,

McGraw Hill Companies Inc,

-613.

2

010:393-408.

4

.

Huq S, Hassan MI, Malek MA,

Faruque AS, Salam MA. Hypogly-

caemia in under-five children with

diarrhea. J Trop Paediatr

1

1. Reid S, McQuillan S, Losek J.

Hypoglycemia complicating dehy-

dration due to acute gastroenteritis.

Clin Pediatr (Phila) 2003;42

2

007;53:197-201.

(7):641-646.

5

6

.

Reid SR, Losek JD. Hypoglycae-

mia complicating dehydration in

children with acute gastroenteritis.

J Emerg Med 2005;29:141-145.

Bennish ML, Azad AK, Rahman

D, Philipe RE. Hypoglycaemia

during diarrhea in childhood:

Prevalence, pathophysiology and

outcome. International Centre for

Diarrhoeal Disease Research,

Bangladesh, Dhaka. N Engl J Med

2. Osier FHA, Berkley JA, Ross A,

Sanderson F, Mohammed S, New-

ton CRJC. Abnormal blood glu-

cose concentrations on admission

to a rural Kenyan district hospital:

prevalence and outcome. Arch Dis

Child 2003;88:621-625.

3. Ogbonnaya O, Nebe A, Chigozie

U, Ekperechi SA. Aetiology of

acute infantile diarrhea and antibi-

otic sensitivity profile. Inter J

1

990;322:1357-1363.

Third World Med 2008;5:153-159.

4. Chesbrough M. District Labora-

tory Practice in Tropical Countries

7

.

Ntia HN, Anah MU, Udo JJ, Ewa

AU, Onubi J. Prevalence of hypo-

glycaemia in under-five children

presenting with acute diarrhoea in

University of Calabar Teaching

Hospital, Calabar. Niger J Paedi-

atr 2012;39(2):63-66.

(Part 1). Cambridge, Cambridge

University Press, 1998:340-348.