Niger J Paed 2014; 41 (4): 316 - 320

ORIGINAL

Onyiriuka AN

Paediatric endocrine disorders as

Kouyaté M

seen at the University of Benin

Teaching Hospital over a

ten-year period

DOI:http://dx.doi.org/10.4314/njp.v41i4,5

Accepted: 9th April 2014

Abstract Background: In most

Results : A total of 13,735 new

developing countries, data on the

cases were seen in the Department

Onyiriuka AN (

)

prevalence and distribution of

Endocrine and Metabolic Unit,

of Child Health, UBTH during the

Department of Child Health

paediatric endocrine disorders is

ten-year period under review and

University of Benin Teaching Hospital,

lacking.

99 (0.72%) of these had endocrine

PMB 1111,

Objective : To describe the pattern

disorders. The frequencies of the

Benin City, Nigeria.

of endocrine disorders seen in the

four leading groups of endocrine

E-mail: alpndiony@yahoo.com

Department of Child Health, Uni-

disorders seen were as follows:

didiruka@gmail.com

versity of Benin Teaching Hospi-

diabetes mellitus 17.2%; disorders

tal (UBTH), Benin City, Nigeria

of sex development 13.8%; disor-

Kouyaté M

between 2004 to 2013.

ders of the thyroid gland 12.1%;

Service de Pédiatrie,

Methods : In this retrospective

Unité d’endocrinologie pédiatrique

and disorders of energy balance

Hôpital National de Donka,

study, the case files of children

11.2%. Short stature was a rare

CHU de Conakry, Guinea.

seen in the paediatric endocrine-

presenting complaint.

metabolic clinic and those admit-

Conclusion: Diabetes mellitus and

ted into the wards at the UBTH,

disorders involving sex develop-

Benin City from January, 2004 to

ment, thyroid gland, energy bal-

December, 2013 were audited.

ance and pubertal development

Information obtained included age

were the five leading groups of

at presentation, gender, principal

childhood

endocrine

disorders

complaints, and final diagnosis.

encountered in our clinical practice

For those who were admitted, the

in UBTH.

outcome was noted. The hospi-

tal’s paediatric clinic register was

Key words: endocrine disorders,

examined to obtain the total num-

clinical pattern, children, hospital,

ber of new cases seen during the

Nigeria.

period under review.

Introduction

As a group, developing countries of the world experi-

ence 90% of the world’s disease burden but have only

10% of global healthcare funds at their disposal . The

3

In the paediatric age group, endocrine disorders occur

both in developed and developing countries. However,

implication is that strategies for improving healthcare

there are fewer reports concerning the pattern of paediat-

should be selective and based on a rational setting of

ric endocrine disorders from developing compared with

priorities for health. In this regard, knowledge of mor-

developed countries . In most tropical developing coun-

1

bidity profile will assist policymakers, healthcare plan-

tries of Africa, endocrine disorders are ranked low in

ners and administrators to reach informed decisions on

terms of priority by healthcare planners and administra-

allocation of resources to the various areas within the

tors, resulting in merger allocation of resources to that

health sub-sector. Although hospital-based data are in-

area within the health sub-sector . Factors believed to be

2

evitably referral- and access-biased, they provide sub-

responsible for this situation include the heavy burden

stantial insight into the types of diseases, the age of

imposed by infectious diseases and nutritional disorders,

presentation and their burden on in-patient service. In

historical bias suggesting that endocrine disorders are

addition, they, to some extent, reflect the morbidity pat-

tern in the communities .

4

rare in tropical Africa, scarcity of trained paediatric en-

docrinologists and inadequate facility for accurate diag-

nosis in our region . In addition, an endocrine problem

1,2

There is paucity of information in the literature concern-

such as short stature is perceived by the larger society as

ing the pattern of childhood endocrine disorders in Edo

having only social or cosmetic implication. As a conse-

State, Nigeria. The same is true when other parts of our

quence, it is not usually brought to the attention of a

country are considered. Although childhood endocrine

physician .

2

disorders are relatively uncommon, they tend to run a

317

chronic course, resulting in long-term morbidity and,

(59.6%) were females, resulting in male-to-female ratio

sometimes, mortality, if not diagnosed and treated

of 1:1.5; Odds ratio, OR = 0.52, Confidence interval, CI

promptly. However, some endocrine-metabolic disor-

= 0.42-0.62. Excluding the ten infants whose mothers

ders like acute adrenal failure, hypoglycaemia and dia-

had endocrine disorders in pregnancy, the overall mean

betic ketoacidosis present as medical emergencies.

age was 5.4±3.3 years (95% CI = 4.8-6.0) with a range

It has been documented that the most common endo-

of one month to 17 years. As shown in Table 1, those

crine disorder in childhood and adolescence is diabetes

patients with diabetes mellitus and thyroid disorders

mellitus. For instance, Rosenbloom et al , stated that in

5

tended to present during adolescence while those with

paediatric endocrinology practice, diabetes mellitus ac-

anomalies of the external genitalia tended to present

counted for 50% to 60% of the workload. The report of

during infancy.

a recent hospital-based study in Port Harcourt, Nigeria,

indicated that diabetes mellitus was the most common

Table 1: Distribution of subjects according to broad groups of

endocrine disorder in the paediatric age group . Reports

6

endocrine disorders

from African countries suggest an upward trend in the

Endocrine disorders

Mean age

95% CI

Sex

incidence of diabetes mellitus as well as obesity

7-10

.

(years)

ratio

at presentation

M:F

The purpose of present study was to describe the pattern

Diabetes mellitus (n=20)

11.5±3.9

9.8-13.2

1:1.5

of paediatric endocrine disorders seen between January,

Disorders of sex development (n=16)

1.3±1.1

0.8-1.8

1:2

2004 and December, 2013 at the Department of Child

Disorders of thyroid gland (n=14)

12.1±3.2

10.4-13.8

1:2

Health, University of Benin Teaching Hospital (UBTH),

Disorders of energy balance (n=13)

4.2±3.4

2.4-6.0

1:1.7

Disorders of pubertal development

6.7±2.8

5.1-8.3

1:6

Benin City, Nigeria.

(n=12)

Disorders of calcium and bone

3.3±2.5

2.0-4.6

1:1.7

metabolism (n=10)

Disorders of adrenal gland (n=10)

0.9±0.8

0.4-1.4

1:2.5

Infants born to mothers with

0.06±0.04

0.04-0.08

1:1

Patients and methods

endocrine disorder (n=10)

Disorders of growth (n=4)

9.3±2.2

7.1-11.5

3:1

This retrospective study was conducted in the Depart-

ment of Child Health, UBTH, Benin City, Nigeria. Pa-

CI = Confidence Interval

tients seen in the hospital come from Edo State and the

Table 2: Distribution of paediatric endocrine disorders seen

neighbouring states of Delta, Ondo and Kogi. The paedi-

over a ten-year period

atric endocrine-metabolic clinic of UBTH receives refer-

Endocrine disorders

No

%

rals from both within and outside the hospital (UBTH).

In this retrospective study, the case files of all children

Diabetes mellitus

20

20.2*

-

Type 1

15

75.0

seen at the paediatric endocrine-metabolic clinic and

- Type 2

2

10.0

those admitted into the wards at the UBTH, Benin City

- Drug-induced (steroid-induced)

1

5.0

were retrieved and audited. Information obtained from

- Diabetes mellitus co-existing with sickle cell anae-

2

10.0

the case files included age at presentation, gender, prin-

mia

0

0.0

- Others

cipal complaints and final diagnoses. Outcome meas-

Disorders of the thyroid gland

16

16.2*

ures, such as discharged home, discharged but aban-

- Hyperthyroidism

8

50.0

doned, discharged against medical advice, and death

- Hypothyroidism

3

18.7

were also noted in those who were admitted. Patients

- Euthyroid goiter

5

31.3

Disorders of energy balance

14

14.1*

were routinely evaluated, using detailed history and

- Obesity (BMI > 95 percentile)

th

6

42.9

physical examination. The investigations for each case

- Failure to thrive

3

21.4

were usually directed by the individual patient’s history

- Persistent hypoglycaemia

5

35.7

and physical examination findings. The total number of

Disorders of pubertal development

13

13.1*

Delayed puberty

2

15.4

new cases seen during the period was obtained from the

Precocious puberty

6

46.1

relevant clinic and ward registers. Descriptive statistics

Premature thelarche

4

30.8

such as frequencies, means, ratios, standard deviations,

Gynaecomastia

1

7.7

confidence intervals, odds ratios and percentages were

Disorders of adrenal gland

12

12.1*

Congenital adrenal hyperplasia

6

50.0

used to describe all the variables.

Acute adrenal insufficiency (Associated with menin-

gococcaemia)

3

25.0

Iatrogenic Cushing syndrome

3

25.0

Disorders of calcium and bone metabolism

10

12.1*

Rickets

7

70.0

Results

Spondylometaphyseal dysplasia

1

10.0

Blount’s disease

2

20.0

During the ten-year period covered by this review,

Infants born to mothers with endocrine disorders

10

12.1*

13,735 new cases comprising 7,760 (56.5%) males and

Diabetes mellitus

8

80.0

Hyperthyroidim

2

20.0

5,975(43.5%) females were seen at the paediatric con-

Disorders of growth

4

4.0*

sulting Outpatients’ Clinic of UBTH, Benin City, giving

Short stature

4

100.0

a male-to-female ratio of 1.3:1. Ninety nine (0.72%) of

Tall stature

0

0.0

the 13,735 new cases had endocrine disorders, giving an

Total

99

100.0*

incidence of 7 per 1,000 new cases. Of the 99 patients

*Percentage of total number of endocrine cases

with endocrine disorders, 40(40.4%) were males and 59

318

As depicted in Table 2, diabetes mellitus, disorders in-

together they may have contributed to the overall female

volving sex development, the

thyroid gland, energy

preponderance observed in the present study. There is no

balance and pubertal development were the five leading

readily available explanation for higher frequency of

groups of childhood endocrine disorders seen in our

endocrine disorders found among females. It has been

hospital during the period under review. Of the four

documented that all types of simple goitre are more

cases of short stature, only one presented with short stat-

common in females than males because of the presence

of oestrogen receptors in thyroid tissues.

19

ure as the principal complaint (Table 2). Thirty five

Besides, in

(35.4%) of 99 were hospitalized and majority (48.8%)

adolescence, autoimmune thyroid disorders such as

were newly diagnosed cases of diabetes mellitus. The

chronic lymphocytic thyroiditis and Grave’s disease are

more common in girls than boys.

20

outcome of those cases that were hospitalization was as

follows: discharged home 30(85.7%); discharged against

medical advice 2(5.7%); discharged but abandoned

In this series, the four leading groups of endocrine disor-

1(2.9%); and death 2(5.7%). The two deaths were one

ders encountered were diabetes mellitus, disorders of

5-week old boy with persistent hypoglycaemia and one

sex development, disorders of the thyroid gland, and

10-month old boy with acute adrenal failure secondary

disorders of energy balance.

In keeping with a recent

to meningococcaemia.

study at the teaching hospital in Port Harcourt, Nigeria,

diabetes mellitus was the most frequently encountered

problem in our paediatric endocrine-metabolic clinic. In

6

sharp contrast with the report of the study in Port Har-

court, disorders of sex development ranked second in

6

Discussion

frequency in the present study. Disorders of sex devel-

Data from the present study indicate that endocrine dis-

opment was conspicuously absent in the series from Port

Harcourt. The reason for this difference is not clear. In

6

orders accounted for 0.72% of all new cases seen at the

Paediatric Outpatient Clinic of the Department of Child

the present study, thyroid disorders ranked third in fre-

Health, University of Benin Teaching Hospital (UBTH),

quency but ranked very low in the series reported from

Port Harcourt, Nigeria . The authors in that study attrib-

6

Benin City. This confirms that endocrine disorders do

occur in children in tropical countries of Africa despite

uted the low incidence of thyroid gland disorders to

underreporting and missed diagnosis . However, other

6

the huge burden of infectious diseases and nutritional

disorders plaguing the region. Lack of previous pub-

Nigerian studies that have reported that thyroid gland

lished reports on the frequency of endocrine disorders in

disorders was next to diabetes mellitus in terms of

frequency of occurrence involved adults

21,22

the paediatric age group, either our hospital or any other

.

hospital in Edo or Delta state, made comparison with the

present frequency impossible. A recent report on the

In Nigeria, majority of the studies related to thyroid dis-

pattern of childhood endocrine disorders as seen at the

orders involved only adults, making comparison with

teaching hospital in Port Harcourt, Nigeria was silent on

the present study involving the paediatric age group dif-

prevalence . As a consequence, comparison of the fre-

6

ficult. It is known that the pattern as well as the preva-

quency being reported here with frequency in other parts

lence of thyroid disorders in adults differ from that of

children and adolescents

13,23

of Nigeria was impossible.

However, three-and-half

. Other areas of difference

decades ago, endocrine disorders accounted for 0.2% of

between the present study and that in Port Harcourt were

all new cases seen at the Department of Paediatrics, Uni-

the absence of cases of rickets and congenital adrenal

hyperplasia (CAH) in the latter study. The reason for

6

versity College Hospital (UCH), Ibadan . The higher

11

prevalence (almost a four-fold increase) observed in the

the differences observed is not clear, particularly as both

present study might be a reflection of an increase in the

studies were tertiary-hospital based. Considering that

level of awareness concerning paediatric endocrine dis-

clinicians in other sub-specialties in UBTH, also care for

orders among clinicians and the larger society. For in-

children with rickets, the prevalence of rickets being

stance, since 2009, increasing number of Nigerian paedi-

reported the present study might be a gross underestima-

tion of the true figure. For instance, Bafor et al,

24

atric endocrinology Fellows have been graduating yearly

from the training institutions in Kenya and more re-

reported that 46.0% of 78 children below the age of 17

cently, from Nigeria. As a result, there are more physi-

years presenting with angular deformity of the knees in

cians, and by extension, more health professionals with

their Orthopaedic clinic in UBTH had rickets, suggest-

interest in paediatric endocrine disorders. This may re-

ing that physicians tended to refer most children with

sult in an increase in the number of referrals .

12

angular deformity of the knees to the orthopaedic sur-

geon rather than the paediatrician. In contrast to the

With regard to frequency of childhood endocrine disor-

report of the study from PH that indicated that no case

ders, there was a slight female preponderance. A similar

of CAH was found during the six-year period covered

finding has been reported in previous studies in Nige-

by that review, CAH accounted for 6.5% of all cases

ria

6,11

. Reports from other parts of Africa and the world

seen at the our endocrine-metabolic clinic, representing

indicate that thyroid disorders

13-16

, overweight and obe-

70.0% of all cases of disorders of the adrenal gland.

sity , and precocious puberty are all more common in

17

18

Again, the reason for this difference is not clear. How-

girls than boys. These specific childhood and adoles-

ever, cases of CAH have been reported from other

cence endocrine disorders were among the leading five

teaching hospitals in Nigeria. For instance, Adeleke in

Kano and Sowande in Ile Ife have separately reported

25

26

types of endocrine disorders found in our series. Thus,

319

cases of CAH in their respective health institutions.

accurate and complete information concerning the study

Similarly, Agboola-Abu et al, have also reported cases

27

subjects. Despite this limitation, the study provided an

of CAH at Eko hospital, Lagos. However, it is possible

insight into the prevalence and pattern of paediatric

that differences in methods of classification of paediatric

endocrine-metabolic disorders in our hospital.

endocrine disorders used in the two studies may have

contributed to the observed differences.

In the present study, only one case was brought to the

Conclusion

hospital with short stature as the principal complaint.

Consistent with this observation is that short stature as a

In conclusion, diabetes mellitus and disorders involving

presenting complaint was also conspicuously absent in

sex development, thyroid gland , energy balance and

series reviewed by Anochie et al, over a six-year period

6

pubertal development were the five leading groups of

in PH, Nigeria. The same was true in a review covering

childhood endocrine disorders encountered in our clini-

a seven-year period in Ibadan.

28

This trend may be ac-

cal practice in UBTH. Healthcare planning for Nigerian

counted for by the cultural perception in our society that

children should incorporate endocrine healthcare as an

short stature has only social or cosmetic significance .

28

essential component.

As a result, children with short stature are erroneously

perceived as not requiring medical attention. Lack of

Conflict of Interest: None

awareness of the existence of medical treatment for

Funding: None

short stature might have contributed to the near absence

of cases presenting primarily for short stature in this

series. The practical implication is that

in our commu-

Acknowledgements

nities, we need awareness campaign concerning the as-

sociation between short stature and childhood endocrine

We wish to thank Dr Chinedu L. Onyiriuka for assisting

disorders.

incompiling the list of patients seen in the endocrine-

metabolic clinic that enabled the records department to

One limitation of the present study is its retrospective

retrieve the case notes used in this study. We are also

nature. Lack of ability on the part of the researcher to

grateful to the staff in the records department for assist-

monitor and control data collection is a known drawback

ing in retrieving the case files.

Late Dr R.O.

in any retrospective cohort study,

29

and this applies to

Amiengheme provided care to some of the patients.

the present study. A situation that may result in less

References

1.

Anochie IC, Azubuike JC. Endo-

6.

Anochie IC, Opara PI, Inimgba N.

13. Antony J, Celine TM, Chacko M.

crine and metabolic disorders. In:

Pattern of endocrine diseases in

Spectrum of thyroid disorders: A

Azubuike JC, Nkangieneme KEO

children at the University of Port

retrospective study at medical col-

(editors). Paediatrics and Child

Harcourt Teaching Hospital. Port

lege hospital. Thyroid Res Pract

Health in a Tropical Region. 2

nd

Harcourt Med J 2009;3:145-152 .

2014;11(2):55-59.

ed. Owerri, African Educational

7.

Wild S, Rogie C, Sicrete R, King

14. Brown RS, Haung S. The thyroid

Services, 2007:666-683.

H. Global prevalence of diabetes

and its disorders. In: Brook CGD,

2.

Famuyiwa OO. Problems and

estimates for the year 2005 and

Clayton PE, Brown RS (editors).

challenges in the practice of endo-

projections for 2030. Diabetes

Brook’s Clinical Pediatric Endocri-

nology, 5 ed. Oxford: Blackwell

th

crinology in a developing country

Care 2004;27:1047-1007-1014.

1 – An overview. Nig Med Pract

8.

Kadiki OA, Roacid RB. Incidence

Publishing Ltd, 2005:218-253.

1990;20(1):3-6.

of type 1 diabetes in children (0-14

15. Cooper DS. Hyperthyroidism.

3.

Deen JL, Vos T, Hutty SRA, Tul-

years) in Benghazi, Libya (1991-

Lancet 2003;362(9382):459-468.

loch J. Injuries and non-

2000). Diabetes Metab

16. Weetman AP. Grave’s disease. N

communicable diseases: emerging

2002;28:463-467.

Engl J Med 2000;243(17):1236-

health problems of children in

9.

Misra A, Khurana L. Obesity and

1248.

developing countries. Bull World

metabolic syndrome in developing

17. Peltzer K, Pengpid S. Overweight

Health Organ 1999;77(6):518-

countries. J Clin Endocrinol Metab

and obesity and associated factors

524 .

2008;93(11 Suppl 1):S9-30.

among school-aged adolescents in

4.

Brewster DR, Greenwood BM.

10.

Prentice AM. The emerging epi-

Ghana and Uganda. Int J Environ

Seasonal variation in paediatric

demic of obesity in developing

Res Public Health 2011;8:3859-

diseases in The Gambia, West

countries. Inter J Epidemiol

3870.

Africa. Ann Trop Paediatr

2006;35:93-99.

18. Bridges NA, Christopher JA, Hind-

1993;13:133-146.

11. Laditan AAO, Johnson AOK. Thy-

marsh PC, Brook CGD. Sexual

5.

Rosenbloom AL, Deeb LC, Allen

roid gland disorders in African

precocity:Sex incidence and aetiol-

L, Pollock BH. Characteristics of

children. J Natl Med Assoc

ogy. Arch Dis Child 1994;70:116-

pediatric endocrinology practice: a

1979;71(2):139-141.

118.

workforce study. Endocrinologist

12. African Society for Paediatric and

1998;8:213-218.

Adolescent Endocrinology. News-

letter, volume 1, issue 1, 2011.

320

19. Krukowski ZH. The thyroid and

23. Ezzai S, Sarti DA, Cain DR,

27. Agboola-Abu CF, Aligwekwe PK,

parathyroid glands. In: Williams

Braunstein GD. Thyroid incidenti-

Olowu AO, Kuku SF. Congenital

NS, Bulstrode CJK, O’Connell PR

lomas: prevalence by palpation and

adrenal hyperplasia due to 11 hy-

(editors). Bailey and Love’s Short

ultrasonography. Arch Intern Med

droxylase enzyme deficiency in

Practice of Surgery 25 ed, Ed-

th

1994;154:1838-1840.

three siblings: A brief report. West

ward Arnold (publishers) Ltd

24. Bafor A, Ogbemudia AO, Ume-

Afr J Med 1999;18(2):80-86.

2008:771-806.

bese PFA. Epidemiology of angu-

28. Famuyiwa OO. Short stature at the

20. Huang SA. Thyroid. In: Kappy

lar deformities of the knee in chil-

University College Hospital,

MS, Allen DB, Geffner ME

dren in Benin, Nigeria. Sahel Med

Ibadan, Nigeria. West Afr J Med

(editors). Pediatric Practice: Endo-

J 2008;11(4):114-117.

1992;11(1):62-71.

crinology, New York, McGraw

25. Adeleke SI. Congenital adrenal

29. Greenberg RS, Daniels SR, Flan-

Hill Companies Inc, 2010:107-

hyperplasia due to 11-beta hy-

ders WD, Eley JW, Boring JR, III.

Medical Epidemiology, 4 ed,

th

129.

droxylase deficiency in a female

21. Ogbera AO, Fasanmade O, Ad-

adolescent. World J Innov Med

New York, McGraw Hill Compa-

ediran O. Pattern of thyroid disor-

2009;1(1):1-5.

nies, Inc 2005:132-145.

ders in the south western region of

26. Sowande OA, Adejuyigbe O. Man-

Nigeria. Ethn Dis 2007;17:327-

agement of ambiguous genitalia in

330.

Ile Ife, Nigeria: challenges and

22. Edino ST, Mohammed AZ,

outcome. Afr J Paediatr Surg

Ochicha O. Thyroid gland diseases

2009;6(1):14-18.

in Kano. Niger Postgrad Med J

2004;11:103-106.