Hypothyroidism among children and adolescents with nephrotic syndrome in Mulago National Referral Hospital, Kampala, Uganda; a cross-sectional study.

BACKGROUND: Nephrotic syndrome (NS) is the commonest glomerular disease among children. It is characterized by heavy proteinuria and is a risk factor for hypothyroidism in the affected children. Hypothyroidism is of concern because it affects the physical and intellectual development of children and adolescents. This study sought to establish the prevalence and factors associated with hypothyroidism among children and adolescents with NS. METHODS: A cross-sectional design was used to study 70 children and adolescents aged 1-19 years diagnosed with nephrotic syndrome and being followed up in the kidney clinic in Mulago National Referral Hospital. Questionnaires were used to collect patients' socio-demographics and clinical information. A blood sample was taken for analysis for thyroid stimulating hormone (TSH) and free thyroxine (FT4), renal function tests and serum albumin. Hypothyroidism included both overt and subclinical forms. Overt hypothyroidism was defined as TSH level > 10 mU/L and FT4 < 10pmol/L, or FT4 < 10pmol/l with normal TSH, or TSH < 0.5mU/l. Sub-clinical hypothyroidism was defined as TSH ranging between 5 and10 mU/L with normal age appropriate FT4 levels. Urine samples were collected and taken for a dipstick examination. The data was analyzed using STATA version 14. The Bayesian Logistic regression analysis approach was used to estimate odds ratios (OR) and their associated 95% credible intervals. All predictor variables with p value < 0.05 at frequentist statistical analysis were considered significant. RESULTS: The mean age (standard deviation) of participants was 9 years (3.8). There were more males; 36 of 70 (51.4%). The prevalence of hypothyroidism was 23% (16/70 participants). Of the 16 children with hypothyroidism, 3 (18.7%) had overt hypothyroidism while 13 had subclinical hypothyroidism. Only low serum albumin was found to be strongly associated with hypothyroidism; Bayesian OR 132.57 (CI 9.13-567.10) with a frequentist OR of 37 and a p value of 0.001. CONCLUSION: The prevalence of hypothyroidism among children and adolescent with nephrotic syndrome attending Mulago Hospital paediatric kidney clinic was 23%. Hypoalbuminemia was found to be associated with hypothyroidism. Therefore, children and adolescents that have severely low levels of serum albumin should be screened for hypothyroidism and linked to endocrinologists for care.

Prevalence and factors associated with hypothyroidism in children with sickle cell anemia aged 6 months - 17 years attending the Sickle Cell Clinic, Mulago Hospital, Uganda; a cross-sectional study.

PURPOSE: Hypothyroidism has been reported at a prevalence of 6% in children and adolescents with Sickle cell anemia. In this study, we determined the prevalence and factors associated with hypothyroidism among children with Sickle cell anemia attending the Sickle Cell Clinic, in Mulago hospital, Uganda. METHODS: A cross-sectional study was conducted among children aged 6 months - 17 years with a confirmed diagnosis of Sickle Cell Anemia, with no prior diagnosis of hypothyroidism and in steady state attending the Sickle Cell Clinic in Mulago hospital. Data was collected using a structured questionnaire and a blood sample was used to measure thyroid stimulating hormone and free thyroxine. RESULTS: Of the 332 children enrolled, sixty (18.1%) participants had sub-clinical hypothyroidism (95% CI: 14.3 - 22.6). Factors associated with hypothyroidism included constipation [adjusted odds ratio: 3.1, 95% CI:1.0 - 9.0, p = 0.043] and male sex [adjusted odds ratio:2.0, 95% CI:1.1- 3.5, p = 0.025]. CONCLUSION: Approximately 1 in 5 children (18.1%) had sub-clinical hypothyroidism. Males and children who presented with constipation were more likely to have sub-clinical hypothyroidism.

Nutritional rickets among children admitted with severe pneumonia at Mulago hospital, Uganda: a cross-sectional study.

BACKGROUND: There's abundant sunshine in the tropics but severe rickets is still observed. Nutritional rickets is associated with an increased risk of acute lower respiratory infections. Pneumonia is the leading cause of death in the under 5 -year old children with the highest burden in developing countries. Both Pneumonia and rickets are common in the developing countries and may affect clinical presentation and outcome. This study aimed to determine the prevalence and associated factors of nutritional rickets in children admitted with severe pneumonia. METHODS: This was a cross-sectional study of children aged 2-59 months presenting with severe pneumonia at an emergency unit. We enrolled 221 children between February and June 2012 after consent. A pre-coded questionnaire was used to collect data on socio-demographic, nutritional and past medical history. Physical exam was done for signs of rickets and anthropometric measurements. Serum calcium, phosphorus, and alkaline phosphatase (ALP) were assessed. Children with any physical signs of rickets or biochemical rickets (ALP > 400 IU); had a wrist x-ray done. Nutritional rickets was defined as the presence of radiological changes of cupping or fraying and/ or metaphyseal thickening. Severe pneumonia was defined using the WHO criteria. Statistical analysis was performed using the Stata 10 statistical package. P- value < 0.05 was significant. RESULTS: The prevalence of nutritional rickets among children with severe pneumonia is 9.5%. However, 14.5% had raised ALP (biochemical rickets). The factors independently associated with rickets was an elevated alkaline phosphatase; p-value < 0.001, or 32.95 95% CI (10.54-102.93). Other factors like breastfeeding, big family size, birth order were not significantly associated with rickets. Low serum calcium was detected in 22 (9.9%) of the 221 participants. Overall few children with rickets had typical clinical features of rickets on physical examination. CONCLUSION: Rickets is a common problem in our setting despite ample sunshine. Clinicians should actively assess children for rickets in this setting and screen for rickets in those children at high risk even without clinical features.

Is insulin diluted when stored in water?

BACKGROUND: Insulin storage is a challenge in resource-poor countries. In Uganda, patients were noted to store insulin vials by submerging them in water. OBJECTIVE: To examine whether withdrawing insulin from a vial without adding air back causes a vacuum which allows water to enter the vial, resulting in insulin dilution. METHODS: Seven hundred units of insulin were withdrawn from forty 10 mL vials of 100 units/mL insulin [20 neutral protamine hagedorn (NPH), 20 regular]. In half, air was added back. The vials were weighed (baseline). Half of the vials (10 with added air, 10 without) were submerged in water for 24 h and then air-dried for 24 h. Vials that were not submerged sat at room temperature for 48 h. All vials were weighed 48 h from baseline. RESULTS: Addition of air did not impact the change in weight after submersion (air added: -0.002 ± 0.001 g or -0.2 ± 0.1 unit; no air added: -0.003 ± 0.000 g or -0.3 ± 0 unit, p = 0.57). In a subset of vials in which an additional 240 units were withdrawn before submersion for another 24 h, there was still no difference in weight change in those vials with air added (p = 0.2). CONCLUSION: Withdrawing insulin from a vial without adding air did not result in uptake of water or dilution of insulin in the submerged vial, although it made drawing up the insulin easier. This study did not address the larger concern of bacterial contamination of the rubber stopper during water storage.

Age at menarche in relation to nutritional status and critical life events among rural and urban secondary school girls in post-conflict northern Uganda.

BACKGROUND: Menarche age is an important indicator of reproductive health of a woman or a community. In industrial societies, age at menarche has been declining over the last 150 years with a secular trend, and similar trends have been reported in some developing countries. Menarche age is affected by genetic and environmental cues, including nutrition. The study was designed to determine the age at menarche and its relation to childhood critical life events and nutritional status in post-conflict northern Uganda. METHODS: This was a comparative cross-sectional study of rural and urban secondary school girls in northern Uganda. Structured questionnaires were administered to 274 secondary school girls, aged 12 - 18 years to determine the age at menarche in relation to home location, nutritional status, body composition and critical life events. RESULTS: The mean age at menarche was 13.6 ± 1.3 for rural and 13.3 ± 1.4 years for urban dwelling girls (t = -1.996, p = 0.047). Among the body composition measures, hip circumference was negatively correlated with the age at menarche (r = -0.109, p = 0.036), whereas height, BMI and waist circumference did not correlate with menarche. Paternal (but not maternal) education was associated with earlier menarche (F = 2.959, p = 0.033). Childhood critical life events were not associated with age at menarche. CONCLUSIONS: Age at menarche differed among urban and rural dwelling school girls and dependent on current nutritional status, as manifested by the hip circumference. It was not associated with extreme stressful childhood critical life events.

Hypothyroidism Among Children and Adolescents With Nephrotic Syndrome in Mulago National Referral Hospital, Kampala, Uganda; a Cross-sectional Study.

Background: Nephrotic syndrome (NS) is the commonest glomerular disease among children. It is characterized by heavy proteinuria and is a risk factor for hypothyroidism in the affected children. Hypothyroidism is of concern because it affects the physical and intellectual development of children and adolescents. This study sought to establish the prevalence and factors associated with hypothyroidism among children and adolescents with NS. Methods: A cross-sectional design was used to study 70 children and adolescents aged 1-19 years diagnosed with nephrotic syndrome and being followed up in the kidney clinic in Mulago National Referral Hospital. Questionnaires were used to collect patients' socio-demographics and clinical information. A blood sample was taken for analysis for thyroid stimulating hormone (TSH) and free thyroxine (FT4), renal function tests and serum albumin. Hypothyroidism included both overt and subclinical forms. Overt hypothyroidism was defined as TSH level > 10 mU/L and FT4 < 10pmol/L, or FT4 < 10pmol/l with normal TSH, or TSH < 0.5mU/l. Sub-clinical hypothyroidism was defined as TSH ranging between 5 and10 mU/L with normal age appropriate FT4 levels. Urine samples were collected and taken for a dipstick examination. The data was analyzed using STATA version 14 and a p-value < 0.05 was considered as significant. Results: The mean age (standard deviation) of participants was 9 years (3.8). There were more males; 36 of 70 (51.4%). The prevalence of hypothyroidism was 23% (16/70 participants). Of the 16 children with hypothyroidism, 3 (18.7%) had overt hypothyroidism while 13 had subclinical hypothyroidism. Only low serum albumin, aOR 35.80 (confidence interval 5.97-214.69 and a p value of < 0.001) was associated with hypothyroidism. Conclusion: The prevalence of hypothyroidism among children and adolescent with nephrotic syndrome attending Mulago Hospital paediatric kidney clinic was 23%. Hypolbuminemia was found to be associated with hypothyroidism. Therefore, children and adolescents that have severely low levels of serum albumin should be screened for hypothyroidism and linked to endocrinologists for care.

Vitamin D deficiency in low-birth-weight infants in Uganda; a cross sectional study.

BACKGROUND: Vitamin D deficiency affects 7-86% of infants globally and results in recurrent infections, impaired growth and nutritional rickets. Low-birth-weight infants in Uganda are at risk of vitamin D deficiency due to limited sunlight exposure and dependence on breastmilk. We aimed to determine the prevalence and factors associated with vitamin D deficiency among low-birth-weight infants aged 6 weeks to 6 months at Mulago national referral hospital in Uganda. METHODS: We conducted a cross-sectional study at Mulago Hospital between September 2016 and March 2017. We enrolled infants born with low birth weight between six weeks and six months whose mothers were available and willing to provide informed consent. Upon obtaining informed consent, we administered a structured questionnaire and performed a physical examination on the participants. Blood was drawn for calcium, phosphorus and vitamin D estimation. We measured serum 25 hydroxy vitamin D (25(OH)D) using the electrochemiluminescence method. Vitamin D deficiency and insufficiency were defined as (25(OH)D) < 20ng/ml and from 20ng/ml to <30 ng/ml respectively. To determine factors associated with vitamin D deficiency, we fit multivariable logistic regression models with exposure factors determined a priori. Data were analysed using Stata version 14. RESULTS: We enrolled 297 participants, 49.2% (167/297) of whom were males. The median infant age was nine weeks (interquartile range 7-13). All infants had less than one hour of sunlight exposure and over 90.6% (269/297) had received multivitamin supplements containing vitamin D. The prevalence of vitamin D deficiency was 12.1% (36/297): 95% CI (8.9%-16.4%). The prevalence of vitamin D insufficiency was 19.9% (59/297): 95% CI (15.7%-24.8%). Boys had higher odds of vitamin D deficiency compared to girls [adjusted odds ratio 2.8: 95% CI 1.3-6.1]. CONCLUSION: Vitamin D deficiency was 12.1% among low-birth-weight infants in Uganda although almost all of them had received multivitamin supplements containing vitamin D. We recommend that more studies are done in low-birth-weight infants to assess the risk factors for vitamin D in these population in Uganda.

SARS-CoV-2-Associated Multisystem Inflammatory Syndrome in a Child in Uganda: A Paediatric Experience in a Resource-Limited Setting.

SARS-CoV-2-associated Multisystem Inflammatory Syndrome in children (MIS-C) has been described in developed settings that have reported a high burden of COVID-19 cases. However, to date, there are few published cases of MIS-C that have been described in the African region. MIS-C has high morbidity and even mortality without a prompt diagnosis. We report a case of a 9-year-old girl who presented with typical clinical features of MIS-C in Uganda but had a delay in diagnosis. This case report aims to raise awareness among health providers in similar settings to improve clinical suspicion of MIS-C, facilitate prompt diagnosis and treatment, and thus improve outcomes.

Vitamin D status and associated factors among HIV-infected children and adolescents on antiretroviral therapy in Kampala, Uganda.

BACKGROUND: A high prevalence of suboptimal serum vitamin D has been reported among HIV infected children even in countries with high sunshine abundance throughout the year. Vitamin D is a potent immune modulator of innate and adaptive immune responses. Vitamin D regulates immune responses through the vitamin D receptor on CD4 cells. We aimed to determine the vitamin D status of HIV infected children and factors associated with suboptimal vitamin D. METHODS: This was a cross sectional study. We enrolled children aged between 6 months and 12 years attending an outpatient paediatric HIV clinic. Serum 25-hydroxyvitamin D (25(OH)D) was measured using the electrochemoluminisence method. Suboptimal vitamin D was defined as 25(OH)D <30 ng/ml, vitamin D insufficiency and deficiency were 21-29 ng/ml and <20 ng/ml respectively. Anthropometry, physical exam and medical history were documented. Logistic regression was performed. RESULTS: We enrolled 376 children with mean age (sd) 8.05 years (3.03), a median (IQR) duration of ART of 5.9 years (3.2-8.4). Majority of the children (64%) had been exposed to non nucleoside reverse transcriptase inhibitors (NNRTIs). A third were severely immunosuppressed (CD4% ≤15%) at ART initiation. At the time of the study, the majority (89%) were virologically suppressed (VL <1000 copies/ml). Prevalence of 25(OH)D <30 ng/ml was 49 (13%) of 375 participants and 11 (3%) had 25(OH)D <20 ng/ml. Lopinavir/ritonavir regimen was independently associated with 25(OH)D <30 ng/ml; OR 0.27 CI (0.13-0.57), p value-0.002. Serum 25(OH)D <20 ng/ml was associated with CD4 count ≤15% at ART initiation OR 6.55(1.30-32.9), p value-0.023 and use of NNRTIs; OR 10.9(1.22-96.2), p value-0.03. CONCLUSION: We found a low prevalence of suboptimal vitamin D compared to earlier reports. Severe immunosuppression at ART initiation and use of NNRTIs increases odds of deficiency. Vitamin D supplementation should be considered in severely immunosuppressed children initiating ART.

Fanconi-Bickel syndrome in a Ugandan child - diagnostic challenges in resource-limited settings: a case report.

BACKGROUND: Fanconi-Bickel syndrome is an autosomal recessive disorder of glucose metabolism. It is an extremely rare disorder. Most cases have been reported in consanguineous communities. None of the cases have been reported in Black Africans in sub-Saharan Africa. This case was diagnosed 3 years after initial presentation due to diagnostic challenges and limited awareness of similar metabolic syndromes in our setting. CASE PRESENTATION: We report the case of a 4-year-old boy, born to non-consanguineous Black African parents, who presented with failure to thrive and rachitic features in infancy. Clinical, laboratory, and radiological features were indicative of Fanconi-Bickel syndrome. No genetic testing was done. The diagnosis was made 3 years after the initial presentation due to diagnostic challenges. He showed clinical improvement with the institution of a galactose-free diet. CONCLUSION: Fanconi-Bickel syndrome occurs even in non-consanguineous Black African populations. Therefore, clinicians in resource-poor settings should raise their index of suspicion for such metabolic disorders in settings with a high prevalence of failure to thrive among children.

Prevalence and factors associated with neonatal hypoglycemia in Northern Uganda: a community-based cross-sectional study.

BACKGROUND: Neonatal hypoglycemia is the most common endocrine abnormality in children, which is associated with increased morbidity and mortality. The burden and risk factors of neonatal hypoglycemia in rural communities in sub-Saharan Africa are unknown. OBJECTIVE: To determine the prevalence and risk factors for neonatal hypoglycemia in Lira District, Northern Uganda. METHODS: This was a community-based cross-sectional study, nested in a cluster randomized controlled trial designed to promote health facility births and newborn care practices in Lira District, Northern Uganda. This study recruited neonates born to mothers in the parent study. Random blood glucose was measured using an On Call® Plus glucometer (ACON Laboratories, Inc., 10125 Mesa Road, San Diego, CA, USA). We defined hypoglycemia as a blood glucose of < 47 mg/dl. To determine the factors associated with neonatal hypoglycemia, a multivariable linear regression mixed-effects model was used. RESULTS: We examined 1416 participants of mean age 3.1 days (standard deviation (SD) 2.1) and mean weight of 3.2 kg (SD 0.5). The mean neonatal blood glucose level was 81.6 mg/dl (SD 16.8). The prevalence of a blood glucose concentration of < 47 mg/dl was 2.2% (31/1416): 95% CI 1.2%, 3.9%. The risk factors for neonatal hypoglycemia were delayed breastfeeding initiation [adjusted mean difference, - 2.6; 95% CI, - 4.4, - 0.79] and child age of 3 days or less [adjusted mean, - 12.2; 95% CI, - 14.0, - 10.4]. CONCLUSION: The incidence of neonatal hypoglycemia was low in this community and was predicted by delay in initiating breastfeeding and a child age of 3 days or less. We therefore suggest targeted screening and management of neonatal hypoglycemia among neonates before 3 days of age and those who are delayed in the onset of breastfeeding.

Prevalence and factors associated with dysglycemia among girls in selected boarding secondary schools in Wakiso District, Uganda.

BACKGROUND: There is limited information on dysglycemia in adolescents in low-income countries. The objective of this study was to determine the prevalence and factors associated with dysglycemia among boarding secondary school adolescent girls in a peri-urban district. METHODS: The design was a cross-sectional survey. A total of 688 adolescents from four randomly selected girls-only boarding secondary schools in Wakiso District, Uganda, participated in this study. Fasting plasma glucose, body mass index (BMI), and blood pressure (BP) were measured. A questionnaire was used to assess demographic and lifestyle factors. Suspected dysglycemia was defined using the American Diabetes Association cutoff of fasting glucose ≥5.6 mmol/L. Overweight and hypertension were defined being above two SDs or the 95th percentile of the WHO BMI for age and BP for age reference charts, respectively. Logistic regression was used to determine the factors independently associated with dysglycemia. RESULTS: The mean age of the participants was 15.4 years (SD=1.7 years). Probable dysglycemia was found in 44 of 688 (6.4%) participants, ranging from 3.5% in the least affluent school to 9.8% in the most affluent school. No case of type 2 diabetes was found. 11.6% of the participants were found to have probable hypertension. Dysglycemia was higher in adolescents who were overweight (adjusted OR [AOR] 2.3; 95% CI 1.22-4.48), those with hypertension (AOR 4.0; 95% CI 1.86-8.45), and those who frequently stocked biscuits (AOR 3.0; 95% CI 1.21-7.28). Dysglycemia was lower in older adolescents (AOR 0.3; 95% CI 0.10-0.86) and those who took water with meals (AOR 3.0; 95% CI 1.21-7.28). CONCLUSION: In these predominantly peri-urban boarding secondary schools, 6.4% of the adolescent girls have probable dysglycemia. As Africa undergoes the epidemiological transition, there is a need for closer surveillance for diabetes and hypertension in peri-urban schools and school health measures against lifestyle diseases.

Lipodystrophy among HIV-infected children and adolescents on highly active antiretroviral therapy in Uganda: a cross sectional study.

BACKGROUND: With widespread use of antiretroviral therapy (ART) and prolonged survival of HIV-infected children, toxicities like lipodystrophy are becoming more evident. Little is known about lipodystrophy in children in Uganda yet there is increased use of ART. The aim of this study was to determine the prevalence and factors associated with fat redistribution and metabolic abnormalities among HIV-infected children on highly active antiretroviral therapy (HAART) in Uganda. METHODS: A cross-sectional study of 364 HIV positive children aged between 2 and 18 years on ART were enrolled after consent and assent as appropriate. Sociodemographic, clinical and immunological data were collected and recorded in a questionnaire. Fat redistribution was assessed clinically for physical findings of lipohypertrophy and lipoatrophy. A fasting blood sample was taken for lipid profile and blood glucose analysis. Lipodystrophy was defined as presence of abnormal fat redistribution or metabolic abnormalities or both. The proportion of children with fat redistribution and metabolic abnormalities was calculated. We conducted multivariate analysis for factors associated with lipodystrophy among children with lipodystrophic features and those without. RESULTS: The median age of the participants was eight years (range 2 to 18), with 43% of these aged ≥ 10 years and a male to female ratio of 1.1:1. Majority (65%) had advanced HIV (WHO Stage III/IV) at ART initiation with a mean duration on ART of 3.8 years (± 1.2). The prevalence of fat redistribution and hyperlipidemia was 27.0% and 34.0%, respectively. None of the children had hyperglycaemia. Among the children with hyperlipidemia, 16.8% exhibited hypercholesterolemia and 83% had hypertriglyceridemia. Only 29% of children with fat redistribution had hyperlipidemia. We found significant association between fat redistribution and Tanner stages 2 to 5 OR=2.3 (95%CI 1.3 to 3.8), age ≥ 5 years OR=3.9 (95%CI 1.5 to 9.9) and d4T exposure OR=3.4 (95%CI 2.0 to 5.8). A Tanner stage 2 to 5 was independently associated with hyperlipidemia. No significant association was observed with HIV clinical stage and any of the anthropometric measurements. CONCLUSION: The prevalence of lipodystrophy is high among HIV-infected children on ART with a likelihood of developing fat redistribution and metabolic abnormalities increased during puberty.