Growth parameter assessment of diabetic children in AL-Nasiriya city in

2016_2017

Done by

Fatima Ali

Zahraa Abd

Sarah Jaleel

Supervised by :

Ass.prof Dr.Amin Turki ALtiya

الرحيم الرحمن الله بسميشفين فهو مرضت {واذا

العظيم الله صدقاالية الشعراء 80سورة

Dedication

To our families and our hopeful children

Thankful to childrens families

Diabetic center,Bint_AL_Huda hospital

Dr.Ali Abd Sadoon

Content

-Abstract ………………………………………………page 1

-Introduction ………………………………………….page 2-3

Method and material …………………………………Page 4-5

-Result…………………………………………………page 6-7-8

-Discussion …………………………………………….page 9-10

-Conclusion …………………………………………….page 11

-Reference ………………………………………………page 12-13

Abstract Background : control on diabetes is important factor in growth of children with type1 diabetes.

This study assessed the relationship between control of diabetes and growth parameter of diabetic children.

Method and material: Case _control study , 100 children with diabetes were studied and compare with 100 children with acute flu_like illness as controls .

They were examined for weight by scale, height by stadiometer ,mid arm circumference by tap measure and HbA1c for cases of diabetes only.

Result: the average of HbA1c was 11, 44%, a significant association was seen between BMI and HbA1c (p. <0,05) when HbA1c increase body mass index become underestimated, no significant association between mid-arm circumference and HbA1c (p.>0,05).

Conclusion: our patient need more strict diabetic control to achieve normal physical grow

1

IntroductionDiabetes is one of the main problems in health systems in the world , the incidence of type I diabetes mellitus(DM) is rapidly increasing in specific regions and shows a trend toward earlier age of onset[1].Type IDM account for about 10% of all diabetes affecting 15 million in the world[2]

.DM is a common chronic metabolic disorder and a main problem in health systems[3] with two main types: type I in which the secretion of insulin from the beta cells is reduced or absent, and type II which shows decreased insulin or insulin resistance in skeletal muscle, liver, and adipose tissue [4]. The onset of type I DM is usually during childhood, at an average age of 7 to 15 years; however this disease can be seen at any age [5]. It is an autoimmune disease that is correlated with both genetic and environmental factors [6].

Children with diabetes may experience delayed puberty and eventually reach a lower height than their genetic potential [7]. Normal growth is one of the goals in the treatment of children with diabetes. The use of insulin regimens in patients with newly diagnosed insulin-dependent DM has substantially improved final height prognosis[8] .

Insulin treatment may prevent disorders of the growth hormone axis and allow normal growth in children with diabetes [9]However, some studies have shown that the growth rate in such children is normal and is not related to HbA1C levels.These studies have concluded that the main determinant of growth is not metabolic control because moderate metabolic control can also lead to normal growth[10]. Despite the fact that type I diabetes, like other chronic diseases may have negative effects on growth, it is not clear if the growth is only affected by the duration and control of DM or if other contributing factors also exist[11][12].

According to some studies, patients with type I DM beginning at ages under 5 years have the highest rates of deficiency in height growth during puberty [13][14] . Also a relationship between the onset of DM at a lower age and growth deficit has been demonstrated [15]. However others have reported that children with diabetes were shorter in height at diagnosis compared to healthy children [16][17]. in which the age of diagnosis has apparently been the most important factor affecting the results of these studies[18].

Growth during the first 2 years of life is characterized by a gradual deceleration in both linear growth velocity and rate of weight gain both of which level off at 2_3 years of age[19].Growth during childhood is a relatively stable process, the infancy shift in the growth pattern are complete and the child follows the trajectory attained previously,

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until about the age of 4 years, girls grow slightly faster than boys and both sexes and both sexes then average rate of 5-6 cm/year and 2.5 kg/year until onset of puberty[20]. We done this study to increase awareness about diabetes mellitus and it is complication on growth.

Aim1- Comparative study for growth parameter and body mass index between

diabetic cases and control.

2-For known the effect of control of diabetes mellitus on growth parameter in diabetic children.

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Method and material

Case control study extended from 20/8/2016_1/3/2017,in diabetic center in Dhi_Qar, the study included 100 diabetic as acases and compare with 100 as control attend to Bint_AL_Huda hospital with acute flu_like illness.

Consent from diabetic center and from Bint_al_Huda hospital and verbal consent was taken from parents of patients.

We select cases and control randomly.

We take 100 cases of diabetes mellitus because other studies[19]take similar number of cases.

Inclusion criteria of diabetic patient were age from 1_14 years.

Exclusion criteria free from growth hormone deficiency, hypothyroidism, celiac disease and other disease that have effect on growth.

Questionnaire forma had been prepared that include the following items:-

1-Sociodemographic variable included:-

-age sub classified in to three groups [1-5 years,6-12 years and above 12 years].

-Sex sub classified in to male and female.

-Socioeconomic status sub classified in to three groups [poor(less than 300000), medium(300000-700000),rich(more than 300000)].

-Number of family sub classified in to three groups[3 persons ,4-7 persons, more than 7 persons].

2-Measurement:-

*weight measured by scale.

*height measured by stadiometer in standing position without shoes.

*mid arm circumference measured by tape measure in the clinic.

*Body mass index calculate from equation

BMI =wt(kg)/ht(m2),and subclassified into four groups [under weight(less than 18,5),normal weight (18,5 -24,9),overweight (25 -29,9 ),obesity(30 or more than 30)].

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3-Labrotory investigation included (HbA1c) had been used for cases only.

In this study HbA1c was measured in laboratory of diabetic center or taken from file of patient,

Values of HbA1c sub classified depend on laboratory kits in to four groups [normal (less than 6%), good control (6% -7,9%),fair control (8% -9,9%),poor control (more than 10%)].

Statistical and epidemiological analysis had been by using of Excel sheet and SPSS (Statistical package for social science version 23) through which frequency percentage ,standard deviation ,mean ,p value (p>0,05 not significant ,p<0,05 significant),odds ratio(<1protective,1 no association,>1risky).

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RESULTsociodemography

Table(1) Distribution of study Population according to (age and sex ,income and sex ,number of family and sex)

Control DM

Variable Male Percent100% female Percent

100%

Control cases 100

Male Percent 100% Female Percent

100%

Diabetic cases100

Odds ratio

Age

1_5y years 31 56,36% 34 75,5% 65 3 5,88% 5 10,21% 8 18,53

6_12 years 22 40% 10 22,2% 32 41 80,39% 32 65,31% 73 2,77

>12 years 2 3,64% 1 2,3% 3 7 13,73% 12 24,48% 19 51,45

Socio-economic

poor 19 34,55% 19 42,22% 38 18 35,29% 18 36,73% 36 0,99

medium 27 49,09% 22 48,89% 49 27 52,95% 19 38,77% 46 1,47

rich 9 16,36% 4 8,89% 13 6 11,76% 12 24,48% 18 1,46

Number of family

3 3 5,46% 1 2,23% 4 1 1,96% 0 0 1 6,13

4_7 28 50,91% 17 37,77% 45 35 68,62% 34 69,39% 69 0,38

>7 24 43,63% 27 60% 51 15 29,42% 15 30,62% 30 2,35

In this study 100 cases of diabetes mellitus were studied and compare with 100 control children, the age was 1_14years ,in diabetic cases (51%)male (49%)female. in age group 1_5 years(5,88%)male and (10,21%)female and odds ratio is(18,35), in age group 6_12years(80,39%)male and (65,31%)female and odds ratio is(2,77), in age group above 12 years (13,73%)male and (24,48%)female and odds ratio

is(2,77).according to socioeconomic status ,in the poor socioeconomic status(35,22%)male and (36,73%)female and odds ratio is (0,99), in medium socioeconomic status (52,95%)male and (38,77%)female and odds ratio is (1,47), in rich socioeconomic status(11,76%)male and (24,48%)female and odds ratio is (1,46). According to number of family , the number of family ≤3(1,96%)male and (0%)female and odds ratio is(6,13),the number of family 4_7(68,62%)male and (69,39%)female and odds ratio is (0,38), the number of family >7(29,42%)male and (30,62%)female and odds ratio is (2,35).

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Table(2)

Distribution of body mass index according to sex

DMControlOdds ratio

Percent100%

femalePercent100%

male

Percent100%

femalePercent100%

MaleBMI

0,00244,89%2286,27%4486,66%3976,37%42>18,5 under weight

146,952313,73711,12518,181018,5_24,9Normal weight

0,258,16%40%02,22%11,82%125_29,9over weight

0,160%00%00%03,63%230≤ Obese

According to body mass index ,underweight children (86,27%)male and( 44,89%)female and odds ratio is (0,002), in overweight children (0%)male and (8,16%)female and odds ratio is(0,25), in obese children (0%)male and (0%)female and odds ratio is (0,16)

Table(3)

_Distribution of HBA1C according to body mass index in diabetic cases

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Table(4)

_ Distribution of mid arm circumference according to sex

DMControlOdds ratio

Percent%

femalePercent%

Male

Percent%

femalePercent%

maleMid arm circumference

1,216,2%313.7%711,2%514,5%83rd percentile<

0,002

77,5%3874,5%380.86%3976%423rd_97th

percentile3,0316,3%811,6%60,02%19%597th

percentile>

Table(5)

_ Distribution of HBA1C according to mid arm circumference in diabetic cases

P.VALUE10%>8%_9,9%6%_7,9%6%<femalemalefemalemalefemalemaleFemalemaleMAC∕HBA1C

350200003rd

percentile<<0,0526265576013rd_97th

percentile4510211097th

percentile>

p.valuePoor10%>

Fair8%_9,9%

Good6%_7,9%

6%<HbA1C∕BMI

49971Under weight

>0,0517580Normal weight

3001Over weight

234,664,660,66Mean23,574,504,500,57Stander

deviation

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Discussion

In this study there is some limitation which are they proceeds backwards from outcome to cause (retrospective),control are used to support or refuse any inference ,both exposure and outcome or disease have occurred before the start of the study ,no time and specific tools. Were aiding to estimate insulin assay or c-peptide

.this study resulting in :the age group 1-14years comparable with other study[21] .

most of them at age 6-12years (80,39%)male and (65,31%)female ,there is vigorous epidemiological evidence by studying the odds ratio where it was higher by 25 times when it compare the first and last age groups with the second and last .there is

difference with other study[21] because difference in type of epidemiological study.

based on socioeconomic status most of them medium socioeconomic status (52,15%)male and (38,77%)female ,there is epidemiological evidence by studying the odds ratio of first and second group was protective (<1) while the odds ratio of second and last group was risky (>1).

Based on number of family most of them their was from group number of family (4-7)person(68,62%)male ,(69,39%)female, there is epidemiological evidence by studying the odds ratio where it was higher by 3 times when it compare first and second groups with first and last ,the odds ratio of the second with third group was protective (<1),as seen in table (1).

_the socioeconomic status and number of family don’t mention in other study[21] due to difference in type of epidemiological study .based on body mass index most of cases

were underweight (86,27%)male and (44,89%)female.

there is vigorous epidemiological evidence by studying odds ratio where it was higher by 100 times when compare the first and second group with first and third group ,while odds ratio of second and third was 1 as seen in table (2).based on mid arm - circumference most of cases were between level 3rd_97th percentile for their age and sex (74,5%)male and (77,5%)female ,there is epidemiological evidence by studying odds ratio where it was higher by 3 times when it compare first and last group with first and second while the odds ratio of second and last was protective<1 as seen in table (4).

most of underweight patient was HBA1C level >10% the mean of HbA1c level in cases was (11.44%) ranging from( 5,5% to 17%).difference in mean of HbA1c level based on body mass index were p.value was statically significant(p<0,05)when HbA1c increase body mass index become underestimated as seen in table (3)

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,in other study[21] the mean of HbA1c level was( 8,89%) and difference in mean of HbA1c based on age was not statistically significant (p>0,05),the difference due to type of epidemiological study. HbA1c level based on mid arm circumference ,in this study most of cases which between 3rd _97th percentile(74,5%male and 77,5%female)as seen in table (4), were HbA1c level was poor control(>10%HbA1c) .In this study no statically significant correlation was found between HbA1c and mid arm

circumference (p>0,05) as seen in table (5) .

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ConclusionAccording to this study we have been concluded that extremities of age below 5 years old and above 12 years old less liable to have diabetes mellitus than 6_12 years old , also socioeconomic status as increase is best for control of diabetes mellitus, number of family as decrease is best for control of diabetes mellitus.

Most of diabetic cases were underestimated body mass index (<18, 5kg/m2),(86,27%)male and (44,89%)female.

We recommend the parents of diabetic child to done routine visit to the doctor to do perfect assessment of the growth to the child monitor and give advice about diet and therapy of their child for best growth.

Our patients need more strict diabetic control to achieve normal physical growth.

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2- Ramin Alemzadeh , David T.Wyatt:Diabetes in children:Nelson Textbook of Pediatrics ,Behrman, Kleigman,Jenson 18th Ed 2007- p2405-2425.

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