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Impact of socioeconomic status on sexual maturation of Nigerian boys living with sickle cell anaemia

Impact of socioeconomic status on sexual maturation of Nigerian boys living with sickle cell anaemia Impact of socioeconomic status on sexual maturation of Nigerian boys living with sickle cell anaemia 1,2 1 1 1 U. O. Uchendu , A. N. Ikefuna , A. R. C. Nwokocha and I. J. Emodi Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria Department of Pediatrics, The Brooklyn Hospital Center, Brooklyn, NY, USA Background: Assessment of sexual maturation of children continues to have great relevance in monitoring their overall development. The interplay between innate disease characteristics and environmental modifiers such as socioeconomic status is not clearly understood among children with sickle cell anaemia (SCA). Objective: To evaluate impact of socioeconomic status on sexual development of children living with sickle cell anaemia. Methods: A cross-sectional case-control study evaluating sexual maturation of male patients with SCA (subjects) compared with non-SCAs (controls) was done. Tanner staging and testicular volume (TV) assessment were used for evaluating sexual maturation among both groups matched for age and socioeconomic status. Pattern of sexual maturation was related to socioeconomic status. Results: Subjects demonstrated delay in onset and completion of sexual maturation compared to controls. Testicular volumes of subjects were smaller than controls but when related to Tanner staging showed no significant difference between both groups. Onset of puberty was earlier in children from higher socioeconomic classes though this was very modest and not statistically significant. Similarly children of higher classes showed slightly larger TVs compared with those from lower classes. Conclusion: SCA patients continue to demonstrate delay in sexual maturation compared with controls with normal haemoglobin genotype. Higher socioeconomic status showed a slight improvement on sexual maturation. This should provide a strong basis for advocacy to improve the welfare of families of children living with SCA as a worthwhile measure to improve their development and overall outlook. A larger study of a prospective nature is highly indicated. Keywords: Sexual maturity, sickle cell anaemia, testicular volume, socioeconomic status Introduction human life, and that, as the child matures, the sensitivity of the hypothalamic receptor sites that The physiological mechanisms that determine the mediate inhibitory (suppressive) effects of the gona- onset of puberty remain obscure, although several 2–5 1–4 dal sex steroids declines. The basic trigger of the theories have been proposed. It is thought that the onset of puberty appears to be changes that bring hypothalamo–pituitary–gonadal axis is already func- about a release of the apparent inhibition of the tioning in the foetal and pre-pubertal stages of medial basal hypothalamic neurons which secrete 1,3,6 gonadotropin-releasing hormone. Correspondence to: U. O. Uchendu, The Brooklyn Hospital Center, By the clinical staging of the pubertal changes Brooklyn, New York, USA. E-mail: u4chy2002@yahoo.co.uk using pubic hair and genital development, as pre- W. S. Maney & Son Ltd 2010 Received 23 December 2009; accepted 8 March 2010 414 DOI 10.1179/102453310X12647083621209 Hematology 2010 VOL 15 NO 6 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia sented by Marshal and Tanner, puberty is regarded weekly while the CHOP runs daily except on week- to have started in a male when he has shown features ends. Children seen at the SCC are those referred from in keeping with Tanner stage 2 in either the genital or other sections of the Paediatrics Department or from pubic hair development (PH2 or G2). It could also private or public health institutions in the State and be regarded as the attainment of testicular volume of beyond. Clinical diagnosis of SCA is confirmed at the at least 3 ml and is considered as a more sensitive Haematology Department of UNTH using cellulose predictor of sexual maturation. acetate paper for electrophoresis at pH of 8 6. The onset of these developmental changes is Ethical approval was obtained from the Ethics determined both by the individual’s genetic constitu- Committee of UNTH and informed written consent tion (nature) and environmental influences (nur- was obtained from parents while older patients were 1,5,6 ture). Among several environmental factors that required to give accent before inclusion into the impact negatively on growth and development are study. Sickle cell anaemia patients included into the malnutrition, chronic diseases such as sickle cell study were aged 6–18 years. Children with other anaemia (SCA), end stage renal diseases, etc. Sickle chronic illnesses that could affect growth and sexual cell anaemia is characterized by recurrent episodes of development and those whose ages could not be acute illness referred to as ‘crises’. As a chronic ascertained were excluded. Controls were children disease there are significant complications involving with normal haemoglobin genotype attending CHOP many systems leading to derangement in both for illnesses that affect neither growth nor sexual function and structure. These complications impact maturation. The subjects and controls were matched negatively on growth and sexual maturation of for age and socio-economic status. Socio-economic 8,9 patients with SCA. class (SEC) was assigned by the method of Olusanya The influence of environmental factors on the et al. sexual maturation of SCA patients is not clearly The average attendance at SCC is 20 patients per documented. Beyond the innate characteristics of the week. On the average 3 new patients are registered disease is a need to understand the environmental into the clinic per month while the average new modifiers of the impact of the disease and one of such registration per year for the past 5 years is 40. A total factors would be the socioeconomic status of the of about 700 children attend the SCC, made up of parents of children living with SCA. Socioeconomic about 360 males and 340 females. Of the 360 males status affects an individual’s perception and under- about 200 are aged 6 to 18 years. standing of health promoting measures. It also The minimum sample size for the SCA subjects was determines compliance and utilization of health determined first for an infinite population using an interventions which are components of the environ- appropriate formula which gave 71. An attrition mental determinants of health. It is not clear how factor of 40% was considered to make allowance for socioeconomic status affects the growth and sexual late withdrawal of consent, bringing up the sample maturation of children having SCA in our environ- size to 100. Thus, the sampling ratio was 1 : 2 of the ment. There is need to explore if there is any impact study population. of socioeconomic status on the health, especially Male SCA patients aged 6–18 years were stratified sexual maturation, of these children and to compare by age in order to ensure a non-skewed selection, and this to children without the disease. Identifying this to make allowance for units that will contain the can help provide necessary impetus for health mean ages of attainment of the various Tanner stages education of families and for advocacy on need to as found in a previous study on sexual maturation improve welfare of families of children living with among boys in the area of the study. Subjects were sickle cell anaemia. enrolled consecutively on clinic days. One hundred and one controls were selected to match the age and Patients and methods social class distribution of the subjects. Between April and September 2006, we conducted a Both study groups were examined and stages of cross-sectional survey of children receiving care from sexual maturation determined by the method of the Department of Paediatrics, University of Nigeria Marshall and Tanner, using standard photographs Teaching Hospital (UNTH) Enugu, Nigeria. The as a guide. Testicular size was determined from a 13,14 Paediatrics Department runs various clinics among formula applied to calculate the volume. The skin which is the Sickle Cell (SCC) and the Children of the testis was stretched without compressing the Outpatient (CHOP) Clinics. The SCC runs once testis and the greatest length and width were Hematology 2010 VOL 15 NO 6 415 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia measured with transparent ruler, which was cali- brated in centimetres. This agrees with standard methods. Testicular volume (TV) was calculated using the method of Cantu et al. in which the testis is regarded as an ellipsoid object, and volume equals P 2 /66L6W (in cubic centimetres) where L is the length of testis, W is the width of testis and P is a constant equal to 3 14 (22/7). Volumes of both testes were calculated and an average taken. Data were analyzed with the computer using the Statistical Package for Social Sciences (SPSS Version 11.5). Measures of statistical location were calculated for continuous data and percentages/proportions for discrete data. Proportions were tested using Chi- square test while means were compared with t-tests. Analysis of variance (ANOVA) was applied to compare continuous data of more than two classes. The level of significance is taken as P,0 05. Results One hundred male SCA patients (subjects) and one hundred and one non-SCA patients (controls) matched for age and social class were recruited. Age . . range of both groups was from 6 0to18 0 years with . . a mean of 12 2(3 5) years for the subjects and . . 12 0(3 5) years for controls. Most subjects and controls belonged to the lower . . SEC with relative proportions of 52 0 and 49 5% respectively in that class followed by the middle class (31% versus 30%) and least of all by the upper class (20% versus 18%). The distribution according to stages of pubic hair (PH) development (Table 1) shows that most subjects (75% of SCA patients) were in the early stages of development (PH1) while very few were in the later stages of development. When compared with controls the reverse was the case, with 38 9% controls at PH1. Only 2 (2%) of SCAs achieved PH5 as against 11 (10 9%) controls. The pattern of genital development was similar to PH development both within and across the subgroups (Table 1). Sickle cell anaemia patients showed a delay in the ages of attainment of corresponding genital and pubic hair stages of development in comparison with the controls (Figs. 1 and 2). Onset of puberty was . . . . noticed at 12 0¡2 0 years (G2) and 12 6¡2 3 years . . (PH2) among controls as against 14 7¡1 5 years and . . 15 5¡1 5 years respectively among SCA patients. These differences were statistically significant with P . . values of 0 00001 for G2 and 0 0002 for PH2 (Table 2). Similarly, mean ages of controls at final 416 Hematology 2010 VOL 15 NO 6 Table 1 Distribution of subjects and controls by stages of sexual development PH development G development Subjects Controls Total Subjects Controls Total PH stage No. (%) No. (%) No. (%) Chi-square P value G stage No. (%) No. (%) No. (%) Chi-square P value . . . . . . . . . . 1 75 (75 0) 39 (38 6) 114 (56 7) 27 100 0 001* 1 57 (57 0) 34 (33 7) 91 (45 3) 11 045 0 001* . . . . . . . . . . 28(8 0) 28 (27 7) 36 (17 9) 13 294 0 0003* 2 18 (18 0) 29 (28 7) 47 (23 4) 3 219 0 073 . . . . . . . . . . 3 10 (10 0) 12 (11 9) 22 (10 9) 2 132 0 144 3 19 (19 0) 10 (9 9) 29 (14 4) 0 803 0 370 . . . . . . . . . . 45(5 0) 11 (10 9) 16 (8 0) 0 933 0 334 4 4 (4 0) 11 (10 9) 15 (7 5) 2 380 0 123 . . . . . . . . . . 52(2 0) 11 (10 9) 13 (6 5) 3 455 0 063 5 2 (2 0) 17 (16 8) 19 (9 4) 5 818 0 016* . . . . . . Total 100 (100 0) 101 (100 0) 201 (100 0) Total 100 (100 0) 101 (100 0) 201 (100 0) *Statistically significant. PH, pubic hair; G, genital. Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Figure 1 Mean ages of subjects and controls at various Figure 2 Mean ages of subjects and controls at various genital maturity status pubic hair stages stage of puberty (G5, PH5) were lower when . . and 16 0¡1 6 years for upper, middle and lower . . compared with subjects: 16 0¡1 6 years (G5) and SECs respectively. At genital stage 2(G2) mean ages . . 16 3¡1 6 years (PH5) for controls versus . . . . of subjects were 13 4¡1 0, 14 8¡2 1 and . . 18 0¡0 0 years (both G5 and P5) for subjects. . . 15 0¡1 3 years for upper, middle and lower classes For both subjects and controls, the earliest sign of respectively. Statistically, there was no significant puberty observed was G2 stage at mean ages difference between all the classes. One-way analysis . . . . 14 7¡1 5 years and 12 0¡2 0 years respectively of variance (ANOVA) of differences of the mean ages (Table 3). PH2 stage followed closely in both groups at commencement of genital development (G2) and and it is noteworthy that corresponding G and PH PH2 showed no significant difference both between stages were achieved before the next higher level was and among the three SECs (P values50 282 and commenced, i.e. G2PH2 before G3PH3 and so on. 0 405 for mean ages by SECs at G2 and PH2 Socioeconomic status respectively (Table 2)). . . There were 18, 30 and 52 SCA patients at G2 For controls, mean ages at PH2 were 11 7¡3 0, . . . . belonging to upper, middle and lower SEC respec- 12 8¡2 5 and 12 9¡1 8 years and at G2 were . . . . . . tively. There was no association between SEC and 11 1¡2 9, 12 3¡1 7and 12 5¡1 5 years for upper, distribution in the different G stages of development middle and lower SECs respectively. Thus, controls . . (x 53 144; df58; P50 925). Similarly, the distribu- from the upper class showed PH changes suggesting tion of subjects in the various PH stages showed no commencement of puberty earlier compared with . . association to SEC (x 55 215; df58; P50 734). those from the middle and lastly those of the lower Mean ages of subjects at commencement of pubic class. But again, ANOVA of the mean ages between . . . . hair development (PH2) were 13 8¡0 0, 14 9¡0 7 the three SECs suggests no difference in the mean Table 2 ANOVA of mean ages at G2 and PH2 for subjects and controls among the three socioeconomic classes SCA patients (subjects) Genital development (G2) Pubic hair development (PH2) Sum of Mean Sum of Mean squares df square FP value squares df square FP value . . . . . . . . Between groups (SEC) 5 846 2 2 923 1 380 0 282 Between groups (SEC) 4 840 2 2 420 1 088 0 405 . . . . Within groups (SEC) 31 764 15 2 118 Within groups (SEC) 11 120 5 2 224 . . Total 37 609 17 Total 15 960 7 Non-SCA patients (controls) Genital development (G2) Pubic hair development (PH2) Sum of Mean Sum of Mean squares df square FP value squares df square FP value . . . . . . . . Between groups (SEC) 11 042 2 5 521 1 363 0 274 Between groups (SEC) 7 490 2 3 745 0 697 0 508 . . . . Within groups (SEC) 105 326 26 4 051 Within groups (SEC) 134 400 25 5 376 . . Total 116 368 28 Total 141 890 27 Hematology 2010 VOL 15 NO 6 417 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Table 3 Mean age (years) of subjects and controls in each stage of puberty in chronological order No. (%) Mean age in years (SD) Tanner stage Subjects Controls Subjects Controls t-test P value . . . . . . . . G1 57 (57 0) 34 (33 7) 9 7(2 4) 8 3(1 8) 3 19 0 002* . . . . . . . . PH1 75 (75 0) 39 (38 6) 10 9(2 9) 8 5(1 8) 4 49 0 0001* . . . . . . . . G2 18 (18 0) 29 (28 7) 14 7(1 5) 12 0(2 0) 4 79 0 0001* . . . . . . . . PH2 8 (8 0) 28 (27 7) 15 5(1 5) 12 6(2 3) 3 36 0 002* . . . . . . . . G3 19 (19 0) 10 (9 9) 15 6(1 1) 13 5(3 0) 2 13 0 059 . . . . . . . . PH3 10 (10 0) 12 (11 9) 15 9(0 7) 14 3(1 6) 3 11 0 007* . . . . . . . . G4 4 (4 0) 11 (10 9) 17 4(0 3) 15 1(1 6) 2 82 0 014* . . . . . . . . PH4 5 (5 0) 11 (10 9) 17 5(0 4) 15 5(1 6) 3 98 0 002* . . . . . . . . G5 2 (2 0) 17 (16 8) 18 0(0 0) 15 9(1 6) 1 82 0 087 . . . . . . . . PH5 2 (2 0) 11 (10 9) 18 0(0 0) 16 3(1 6) 1 47 0 169 *Statistically significant. ages at which they began sexual maturation the stages of development (P.0 05). Similarly, the (Table 2). TVs of both subjects and controls matched at similar This same pattern was maintained with respect to stages of PH maturity were comparable and there age at completion of sexual maturation. Subjects and was no statistically significant difference between the . . . controls belonging to higher SECs reached PH5 and two groups (G1: 1 21 versus 0 98; G2: 3 96 versus . . . . . G5 but the number of patients reaching those stages 5 16; G3: 8 09 versus 11 86; G4: 11 48 versus 14 96; . . in the three SECs were quite few, among both G5: 16 12 versus 16 72 all in ml). subjects and controls, as to preclude any further There was a very strong association between the comparison between them. genital stages and TVs of both study groups (Pearson’s . . correlation coefficient, r50 845, P,0 001 for the SCA Testicular volume (TV) . . group and r50 820, P,0 001 for the control group). The mean TVs (Table 4) for controls was signifi- This was also similar for relationship between PH . . cantly higher than for subjects (6 67¡7 2 ml versus stages and TVs for both subjects and controls (r50 903, . . . 3 04¡3 8 ml; P50 0002). The controls attained a TV . . . P,0 001 and r50 809, P,0 001) respectively. . . above 3 ml within the age range 12 0–13 0 years. This Relationship between TVs and socioeconomic status of was earlier than observed among subjects whose . subjects and controls average TV in that age range was 1 70 ml. It is . . Average TVs of subjects were 3 6¡3 8 ml, noteworthy that from age 12 years onwards, the . . . . mean TV of controls were significantly higher than 3 6¡4 6 ml and 3 5¡3 2 ml for upper, middle and those of subjects with (P50 00003). lower SECs respectively. Among controls average . . . . . . Relating the TVs to stages of sexual maturation TVs were 5 8¡7 1 ml, 7 5¡7 1 ml and 6 5¡7 4ml shows that average TV from G1 to G5 for subjects for upper, middle and lower SECs respectively. No . . difference was noticed between mean TVs of subjects and controls were comparable (G1: 0 90 versus 0 94; . . . . . from the different SEC. ANOVA (Table 5) shows G2: 3 1 versus 3 94; G3: 6 37 versus 9 59; G4: 10 81 . . there was no significant difference in the variation of versus 14. 23; G5 16 12 versus 16 17 all in ml) and there was no significant difference between TVs at all the TVs both between and within the various SECs of Table 4 Mean testicular volumes of subjects and controls by age range Subjects Controls 3 3 Age range (years) No. (%) Vol. (SD) in cm No. (%) Vol. (SD) in cm t-test P value . . . . . . . . . . 6 0–7 0 17 (17 0) 0 51 (0 3) 18 (17 8) 0 62 (0 2) 21 170 0 301 . . . . . . . . . . 8 0–9 0 13 (13 0) 0 77 (0 4) 14 (13 9) 1 06 (0 7) 21 374 0 149 . . . . . . . . . . 10 0–11 0 16 (16 0) 0 91 (0 4) 17 (16 8) 1 52 (1 8) 21 342 0 210 . . . . . . . . . . 12 0–13 0 18 (18 0) 1 70 (0 6) 20 (19 8) 5 06 (3 0) 24 837 0 00003* . . . . . . . . . . 14 0–15 0 19 (19 0) 4 17 (2 2) 16 (15 8) 13 96 (3 2) 210 680 0 00001* . . . . . . . . . . 16 0–17 0 15 (15 0) 8 58 (4 2) 13 (12 9) 17 92 (2 4) 27 371 0 00002* . . . . . . . . . 1802(2 0) 16 11 (1 3) 3 (3 0) 21 96 (1 0) 25 882 0 011* . . . . . . . . Combined 100 (100 0) 3 04 (3 8) 101 (100 0) 6 67 (7 2) 24 445 0 0002* *Statistically significant. 418 Hematology 2010 VOL 15 NO 6 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia . . SCA children (F51 148; P50 321). Similarly the respect to completion of sexual maturation when differences between the mean TVs of controls from compared with their normal controls. Whereas the the three different SECs was not significant SCA patients attained both final genital and pubic . . . . (F50 356; P50 701). hair maturity status at 18 0¡0 0 years, their counter- . . . . Since puberty (sexual maturation) is recognized parts did so at 15 9¡1 6 years and 16 3¡1 6 years when G2 is achieved, we conducted a subgroup respectively. This is again similar to the pattern analysis of only the children who had commenced reported by Ozigbo and Nkanginieme with mean . . . . puberty and onwards, i.e. from G2 to G5. There were ages of 18 7¡0 6 years and 19 0¡0 0 years for G5 9, 14 and 20 respectively from the upper, middle and and PH5 respectively. lower SECs among the SCA subjects with mean TVs There is however a reasonably wide difference . . . . . . of 6 3¡3 9, 6 8¡5 2 and 5 0¡4 3 ml. Analysis of between the mean age of onset of sexual maturation variance of mean TVs within and across the three in this present study and that reported by some SECs of SCA patients also showed no significant workers who documented a subnormal pubic hair difference between the mean TVs of the 3 SECs (sum growth pattern in male SCA patients even up to a . . . . of squares5797 942; df542; F-test50 727; P50 490). mean age of 26 6 years. The latter finding has been Similarly, excluding controls below G2 stage, there criticized as a possible reflection of the fact that the were 17, 20, and 30 from upper, middle and lower workers may have had a bias of great interest in . . SECs and their mean TVs were 6 8¡7 3 ml, hypogonadism and thus may have used a group of . . . . 17 11 1¡6 4 ml and 10 1¡7 6 ml respectively. more severely affected patients. In the current ANOVA analysis showed no significant difference study, the first noticeable sign of sexual maturation between the various SECs (sum of squares53537 556; was genital development (G2) but this was closely . . df566; F-test51 844; P50 166). followed by pubic hair development (PH2) and this pattern was maintained for each successive pairs of Discussion stages of development and this agrees with the findings from other studies involving SCA This study demonstrated that a significant delay in 16,17,22 patients and those with normal geno- commencement of pubic hair and genital develop- 7,12,23,24 type. Perhaps the first demonstration of the ment characteristic of puberty still exists among effect of higher socioeconomic class on SCA in our children living with SCA. This is in keeping with 16–18 study population is the relatively fewer number of several earlier studies both from within and 19–21 . . outside Nigeria. The mean age of 14 7¡1 5 years children from the upper class among those seen at the for G2 among our subjects compares remarkably to clinic. The possibilities are that those of higher educational level have learnt to take steps to avoid that by Ozigbo and Nkanginieme among similar having children with SCA leading to a relatively patients from other parts of Nigeria with a mean of . . lower prevalence of the disease among people of 14 6¡1 4 years. Similarly, the mean age for attain- . . higher socioeconomic class. Individuals with higher ment of PH2 (15 5¡1 5 years) is comparable to . . level of education are more likely to be aware of the 14 7¡1 3 years documented in the Port-Harcourt 17 18 series but much lower than that of Oyedeji who need for pre-marital genotype testing and the need to reported the earliest age of pubic hair development in avoid getting into a marriage that will lead to having males to be 20 years. It is noteworthy that Oyedeji children with SCA. Another possible reason is that had only six males aged 13 years and above in his those with better financial status will seek care in study population and most likely, this may have private hospitals which are relatively costlier to limited the findings of his study. Sickle cell anaemia afford compared with government hospitals like patients also demonstrated a significant delay with ours, hence the fewer numbers presenting to us. Table 5 ANOVA of mean TVs for subjects and controls among the three socioeconomic classes Subject (SCA) Controls Sum of Mean Sum of Mean squares df squareFP value squares df squareFP value . . . . . . . . Between groups (SEC) 33 042 2 16 521 1 148 0 321 Between groups (SEC) 37 766 2 18 883 0 356 0 701 . . . . Within groups (SEC) 1395 687 97 14 389 Within groups (SEC) 5196 341 98 53 024 . . Total 1428 729 99 Total 5234 107 100 Hematology 2010 VOL 15 NO 6 419 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Children from the upper socioeconomic class status seen among SCA patients may derive from the showed features of sexual maturation before those of fact that most of them are typically very lean and this the other classes. Thereafter, those from the middle may translate into an overtly similar pattern of sexual class followed and the patients from the lower socio- maturation irrespective of social status of patients. economic class were last to show any features of sexual The failure to detect any statistically significant development. This pattern applied to both subjects difference between the three SECs may also be due to (SCAs) and controls (non-SCAs). A similar trend was the classification method used The method of social observed with respect to the completion of sexual classification applied uses a combination of mater- maturation. However, these differences were less nal and paternal educational level and occupational apparent with completion as against commencement to assign SECs. However, it does not determine the of sexual maturation. This trend on the influence of exact expenses on health needs of the family. Also the socioeconomic status on sexual maturity pattern few numbers of patients within some of the classes agrees with conclusion also reached by Adediran may have affected the power of the study to detect on a population of normal schoolboys without SCA in any differences between them. Enugu. Furthermore, the difference is more pro- The mean TVs of SCA patients were lower than nounced between the extremes of the social classes, those of the controls throughout all age groups but that is, between upper and lower classes. this was only noted to be statistically significant . . Higher socioeconomic status implies higher educa- among those who were 12 0–13 0 years old, at which tional level and better financial empowerment and point the controls had reached G2. Both study hopefully translates to the ability of caregivers to seek groups had achieved TVs of at least 3 ml at 5,29 for early and appropriate medical intervention, commencement of puberty. Earlier workers had understand the need and means for preventive reported that increase in TV to 3 ml or more is the measures, and engage in judicious utilization of best marker for puberty and some feel that the resources to take care of family needs. Thus, children initial phase may be missed if TV is not assessed. This from higher socioeconomic classes are more often shows that TV size of at least 3 0 ml is a good better nourished than their poorer counterparts. It is indicator of onset of puberty for both subjects and expected that children of parents from higher socio- controls. Our data validate this especially with the economic classes would demonstrate better growth demonstration of a very strong association between and development pattern. the various stages of genital and pubic hair develop- ment and average TVs of both subjects and controls The population variation in commencement and on the other hand with very high correlation progression of sexual maturation is thought to be highly related to somatic growth or energetic status coefficients. The tendency for children of higher 25,26 and independent of genetic factors. Expectedly SECs to have larger TVs is noted but the lack of any children of higher socioeconomic status are better statistically significant difference between the mean nourished and tend to have higher energy reserves or TVs of the various socioeconomic classes for both lean body mass. This underlies the effect of socio- subjects and controls is in keeping with the pattern economic status on sexual development with children for Tanner staging. This again suggests that socio- from higher classes performing better than those of economic status may only have minimal effect on lower classes as was marginally demonstrated in our sexual maturation of children with sickle cell study groups. Although the differences were not anaemia. However, we encourage caution with the statistically significant between all classes, the pattern interpretation of this data. 17–22,26,27 was too consistent to be ignored. However, the fact Incidentally, none of the several other studies that the difference was not statistically significant evaluated the influence of socio-economic status on may suggest that the negative impact of the disease sexual maturation of SCA patients, thus making it overshadowed whatever impact social class may difficult to compare current findings with other studies ordinarily have had on the patients. Among SCA in this regard. There is, however, a well established trend patients it has been recognized that assessment of among children with normal genotype in whom it is growth using body mass index is a better indicator of shown that children from more developed Western body size rather than height or weight alone. And countries have earlier onset of sexual development using body mass index it is recognized that leanness is compared with those from poorer nations. This evidence 27,28 characteristic of SCA patients. We may thus, lends credence to the positive impact of socioeconomic conclude that the slight impact of socioeconomic status on sexual maturity. Cameron et al. showed that 420 Hematology 2010 VOL 15 NO 6 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia 10 Olusanya O, Okpere E, Ezimokhai M. The importance of social among urban black children who received good class in voluntary fertility control in a developing country. WAfr nutrition their commencement and progression through Med J 1985; 4: 205–212. 11 Araoye MO. Research methodology with statistics for health and the sexual maturity stages were very much comparable social sciences. Ilorin: Nathadex Publishers, 2004; 115–120. to those of white children so that given the same 12 Adediran A. Sexual maturation of Igbo boys in Enugu (Dissertation). 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Oxford: Oxford University Press, sexual development in rural and urban South African black 1992; 358–360. children. Ann Hum Biol 1993; 20: 583–593. Hematology 2010 VOL 15 NO 6 421 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Hematology Online Taylor & Francis

Impact of socioeconomic status on sexual maturation of Nigerian boys living with sickle cell anaemia

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Taylor & Francis
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© 2010 Maney Publishing
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1607-8454
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1024-5332
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10.1179/102453310X12647083621209
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Abstract

Impact of socioeconomic status on sexual maturation of Nigerian boys living with sickle cell anaemia 1,2 1 1 1 U. O. Uchendu , A. N. Ikefuna , A. R. C. Nwokocha and I. J. Emodi Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria Department of Pediatrics, The Brooklyn Hospital Center, Brooklyn, NY, USA Background: Assessment of sexual maturation of children continues to have great relevance in monitoring their overall development. The interplay between innate disease characteristics and environmental modifiers such as socioeconomic status is not clearly understood among children with sickle cell anaemia (SCA). Objective: To evaluate impact of socioeconomic status on sexual development of children living with sickle cell anaemia. Methods: A cross-sectional case-control study evaluating sexual maturation of male patients with SCA (subjects) compared with non-SCAs (controls) was done. Tanner staging and testicular volume (TV) assessment were used for evaluating sexual maturation among both groups matched for age and socioeconomic status. Pattern of sexual maturation was related to socioeconomic status. Results: Subjects demonstrated delay in onset and completion of sexual maturation compared to controls. Testicular volumes of subjects were smaller than controls but when related to Tanner staging showed no significant difference between both groups. Onset of puberty was earlier in children from higher socioeconomic classes though this was very modest and not statistically significant. Similarly children of higher classes showed slightly larger TVs compared with those from lower classes. Conclusion: SCA patients continue to demonstrate delay in sexual maturation compared with controls with normal haemoglobin genotype. Higher socioeconomic status showed a slight improvement on sexual maturation. This should provide a strong basis for advocacy to improve the welfare of families of children living with SCA as a worthwhile measure to improve their development and overall outlook. A larger study of a prospective nature is highly indicated. Keywords: Sexual maturity, sickle cell anaemia, testicular volume, socioeconomic status Introduction human life, and that, as the child matures, the sensitivity of the hypothalamic receptor sites that The physiological mechanisms that determine the mediate inhibitory (suppressive) effects of the gona- onset of puberty remain obscure, although several 2–5 1–4 dal sex steroids declines. The basic trigger of the theories have been proposed. It is thought that the onset of puberty appears to be changes that bring hypothalamo–pituitary–gonadal axis is already func- about a release of the apparent inhibition of the tioning in the foetal and pre-pubertal stages of medial basal hypothalamic neurons which secrete 1,3,6 gonadotropin-releasing hormone. Correspondence to: U. O. Uchendu, The Brooklyn Hospital Center, By the clinical staging of the pubertal changes Brooklyn, New York, USA. E-mail: u4chy2002@yahoo.co.uk using pubic hair and genital development, as pre- W. S. Maney & Son Ltd 2010 Received 23 December 2009; accepted 8 March 2010 414 DOI 10.1179/102453310X12647083621209 Hematology 2010 VOL 15 NO 6 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia sented by Marshal and Tanner, puberty is regarded weekly while the CHOP runs daily except on week- to have started in a male when he has shown features ends. Children seen at the SCC are those referred from in keeping with Tanner stage 2 in either the genital or other sections of the Paediatrics Department or from pubic hair development (PH2 or G2). It could also private or public health institutions in the State and be regarded as the attainment of testicular volume of beyond. Clinical diagnosis of SCA is confirmed at the at least 3 ml and is considered as a more sensitive Haematology Department of UNTH using cellulose predictor of sexual maturation. acetate paper for electrophoresis at pH of 8 6. The onset of these developmental changes is Ethical approval was obtained from the Ethics determined both by the individual’s genetic constitu- Committee of UNTH and informed written consent tion (nature) and environmental influences (nur- was obtained from parents while older patients were 1,5,6 ture). Among several environmental factors that required to give accent before inclusion into the impact negatively on growth and development are study. Sickle cell anaemia patients included into the malnutrition, chronic diseases such as sickle cell study were aged 6–18 years. Children with other anaemia (SCA), end stage renal diseases, etc. Sickle chronic illnesses that could affect growth and sexual cell anaemia is characterized by recurrent episodes of development and those whose ages could not be acute illness referred to as ‘crises’. As a chronic ascertained were excluded. Controls were children disease there are significant complications involving with normal haemoglobin genotype attending CHOP many systems leading to derangement in both for illnesses that affect neither growth nor sexual function and structure. These complications impact maturation. The subjects and controls were matched negatively on growth and sexual maturation of for age and socio-economic status. Socio-economic 8,9 patients with SCA. class (SEC) was assigned by the method of Olusanya The influence of environmental factors on the et al. sexual maturation of SCA patients is not clearly The average attendance at SCC is 20 patients per documented. Beyond the innate characteristics of the week. On the average 3 new patients are registered disease is a need to understand the environmental into the clinic per month while the average new modifiers of the impact of the disease and one of such registration per year for the past 5 years is 40. A total factors would be the socioeconomic status of the of about 700 children attend the SCC, made up of parents of children living with SCA. Socioeconomic about 360 males and 340 females. Of the 360 males status affects an individual’s perception and under- about 200 are aged 6 to 18 years. standing of health promoting measures. It also The minimum sample size for the SCA subjects was determines compliance and utilization of health determined first for an infinite population using an interventions which are components of the environ- appropriate formula which gave 71. An attrition mental determinants of health. It is not clear how factor of 40% was considered to make allowance for socioeconomic status affects the growth and sexual late withdrawal of consent, bringing up the sample maturation of children having SCA in our environ- size to 100. Thus, the sampling ratio was 1 : 2 of the ment. There is need to explore if there is any impact study population. of socioeconomic status on the health, especially Male SCA patients aged 6–18 years were stratified sexual maturation, of these children and to compare by age in order to ensure a non-skewed selection, and this to children without the disease. Identifying this to make allowance for units that will contain the can help provide necessary impetus for health mean ages of attainment of the various Tanner stages education of families and for advocacy on need to as found in a previous study on sexual maturation improve welfare of families of children living with among boys in the area of the study. Subjects were sickle cell anaemia. enrolled consecutively on clinic days. One hundred and one controls were selected to match the age and Patients and methods social class distribution of the subjects. Between April and September 2006, we conducted a Both study groups were examined and stages of cross-sectional survey of children receiving care from sexual maturation determined by the method of the Department of Paediatrics, University of Nigeria Marshall and Tanner, using standard photographs Teaching Hospital (UNTH) Enugu, Nigeria. The as a guide. Testicular size was determined from a 13,14 Paediatrics Department runs various clinics among formula applied to calculate the volume. The skin which is the Sickle Cell (SCC) and the Children of the testis was stretched without compressing the Outpatient (CHOP) Clinics. The SCC runs once testis and the greatest length and width were Hematology 2010 VOL 15 NO 6 415 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia measured with transparent ruler, which was cali- brated in centimetres. This agrees with standard methods. Testicular volume (TV) was calculated using the method of Cantu et al. in which the testis is regarded as an ellipsoid object, and volume equals P 2 /66L6W (in cubic centimetres) where L is the length of testis, W is the width of testis and P is a constant equal to 3 14 (22/7). Volumes of both testes were calculated and an average taken. Data were analyzed with the computer using the Statistical Package for Social Sciences (SPSS Version 11.5). Measures of statistical location were calculated for continuous data and percentages/proportions for discrete data. Proportions were tested using Chi- square test while means were compared with t-tests. Analysis of variance (ANOVA) was applied to compare continuous data of more than two classes. The level of significance is taken as P,0 05. Results One hundred male SCA patients (subjects) and one hundred and one non-SCA patients (controls) matched for age and social class were recruited. Age . . range of both groups was from 6 0to18 0 years with . . a mean of 12 2(3 5) years for the subjects and . . 12 0(3 5) years for controls. Most subjects and controls belonged to the lower . . SEC with relative proportions of 52 0 and 49 5% respectively in that class followed by the middle class (31% versus 30%) and least of all by the upper class (20% versus 18%). The distribution according to stages of pubic hair (PH) development (Table 1) shows that most subjects (75% of SCA patients) were in the early stages of development (PH1) while very few were in the later stages of development. When compared with controls the reverse was the case, with 38 9% controls at PH1. Only 2 (2%) of SCAs achieved PH5 as against 11 (10 9%) controls. The pattern of genital development was similar to PH development both within and across the subgroups (Table 1). Sickle cell anaemia patients showed a delay in the ages of attainment of corresponding genital and pubic hair stages of development in comparison with the controls (Figs. 1 and 2). Onset of puberty was . . . . noticed at 12 0¡2 0 years (G2) and 12 6¡2 3 years . . (PH2) among controls as against 14 7¡1 5 years and . . 15 5¡1 5 years respectively among SCA patients. These differences were statistically significant with P . . values of 0 00001 for G2 and 0 0002 for PH2 (Table 2). Similarly, mean ages of controls at final 416 Hematology 2010 VOL 15 NO 6 Table 1 Distribution of subjects and controls by stages of sexual development PH development G development Subjects Controls Total Subjects Controls Total PH stage No. (%) No. (%) No. (%) Chi-square P value G stage No. (%) No. (%) No. (%) Chi-square P value . . . . . . . . . . 1 75 (75 0) 39 (38 6) 114 (56 7) 27 100 0 001* 1 57 (57 0) 34 (33 7) 91 (45 3) 11 045 0 001* . . . . . . . . . . 28(8 0) 28 (27 7) 36 (17 9) 13 294 0 0003* 2 18 (18 0) 29 (28 7) 47 (23 4) 3 219 0 073 . . . . . . . . . . 3 10 (10 0) 12 (11 9) 22 (10 9) 2 132 0 144 3 19 (19 0) 10 (9 9) 29 (14 4) 0 803 0 370 . . . . . . . . . . 45(5 0) 11 (10 9) 16 (8 0) 0 933 0 334 4 4 (4 0) 11 (10 9) 15 (7 5) 2 380 0 123 . . . . . . . . . . 52(2 0) 11 (10 9) 13 (6 5) 3 455 0 063 5 2 (2 0) 17 (16 8) 19 (9 4) 5 818 0 016* . . . . . . Total 100 (100 0) 101 (100 0) 201 (100 0) Total 100 (100 0) 101 (100 0) 201 (100 0) *Statistically significant. PH, pubic hair; G, genital. Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Figure 1 Mean ages of subjects and controls at various Figure 2 Mean ages of subjects and controls at various genital maturity status pubic hair stages stage of puberty (G5, PH5) were lower when . . and 16 0¡1 6 years for upper, middle and lower . . compared with subjects: 16 0¡1 6 years (G5) and SECs respectively. At genital stage 2(G2) mean ages . . 16 3¡1 6 years (PH5) for controls versus . . . . of subjects were 13 4¡1 0, 14 8¡2 1 and . . 18 0¡0 0 years (both G5 and P5) for subjects. . . 15 0¡1 3 years for upper, middle and lower classes For both subjects and controls, the earliest sign of respectively. Statistically, there was no significant puberty observed was G2 stage at mean ages difference between all the classes. One-way analysis . . . . 14 7¡1 5 years and 12 0¡2 0 years respectively of variance (ANOVA) of differences of the mean ages (Table 3). PH2 stage followed closely in both groups at commencement of genital development (G2) and and it is noteworthy that corresponding G and PH PH2 showed no significant difference both between stages were achieved before the next higher level was and among the three SECs (P values50 282 and commenced, i.e. G2PH2 before G3PH3 and so on. 0 405 for mean ages by SECs at G2 and PH2 Socioeconomic status respectively (Table 2)). . . There were 18, 30 and 52 SCA patients at G2 For controls, mean ages at PH2 were 11 7¡3 0, . . . . belonging to upper, middle and lower SEC respec- 12 8¡2 5 and 12 9¡1 8 years and at G2 were . . . . . . tively. There was no association between SEC and 11 1¡2 9, 12 3¡1 7and 12 5¡1 5 years for upper, distribution in the different G stages of development middle and lower SECs respectively. Thus, controls . . (x 53 144; df58; P50 925). Similarly, the distribu- from the upper class showed PH changes suggesting tion of subjects in the various PH stages showed no commencement of puberty earlier compared with . . association to SEC (x 55 215; df58; P50 734). those from the middle and lastly those of the lower Mean ages of subjects at commencement of pubic class. But again, ANOVA of the mean ages between . . . . hair development (PH2) were 13 8¡0 0, 14 9¡0 7 the three SECs suggests no difference in the mean Table 2 ANOVA of mean ages at G2 and PH2 for subjects and controls among the three socioeconomic classes SCA patients (subjects) Genital development (G2) Pubic hair development (PH2) Sum of Mean Sum of Mean squares df square FP value squares df square FP value . . . . . . . . Between groups (SEC) 5 846 2 2 923 1 380 0 282 Between groups (SEC) 4 840 2 2 420 1 088 0 405 . . . . Within groups (SEC) 31 764 15 2 118 Within groups (SEC) 11 120 5 2 224 . . Total 37 609 17 Total 15 960 7 Non-SCA patients (controls) Genital development (G2) Pubic hair development (PH2) Sum of Mean Sum of Mean squares df square FP value squares df square FP value . . . . . . . . Between groups (SEC) 11 042 2 5 521 1 363 0 274 Between groups (SEC) 7 490 2 3 745 0 697 0 508 . . . . Within groups (SEC) 105 326 26 4 051 Within groups (SEC) 134 400 25 5 376 . . Total 116 368 28 Total 141 890 27 Hematology 2010 VOL 15 NO 6 417 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Table 3 Mean age (years) of subjects and controls in each stage of puberty in chronological order No. (%) Mean age in years (SD) Tanner stage Subjects Controls Subjects Controls t-test P value . . . . . . . . G1 57 (57 0) 34 (33 7) 9 7(2 4) 8 3(1 8) 3 19 0 002* . . . . . . . . PH1 75 (75 0) 39 (38 6) 10 9(2 9) 8 5(1 8) 4 49 0 0001* . . . . . . . . G2 18 (18 0) 29 (28 7) 14 7(1 5) 12 0(2 0) 4 79 0 0001* . . . . . . . . PH2 8 (8 0) 28 (27 7) 15 5(1 5) 12 6(2 3) 3 36 0 002* . . . . . . . . G3 19 (19 0) 10 (9 9) 15 6(1 1) 13 5(3 0) 2 13 0 059 . . . . . . . . PH3 10 (10 0) 12 (11 9) 15 9(0 7) 14 3(1 6) 3 11 0 007* . . . . . . . . G4 4 (4 0) 11 (10 9) 17 4(0 3) 15 1(1 6) 2 82 0 014* . . . . . . . . PH4 5 (5 0) 11 (10 9) 17 5(0 4) 15 5(1 6) 3 98 0 002* . . . . . . . . G5 2 (2 0) 17 (16 8) 18 0(0 0) 15 9(1 6) 1 82 0 087 . . . . . . . . PH5 2 (2 0) 11 (10 9) 18 0(0 0) 16 3(1 6) 1 47 0 169 *Statistically significant. ages at which they began sexual maturation the stages of development (P.0 05). Similarly, the (Table 2). TVs of both subjects and controls matched at similar This same pattern was maintained with respect to stages of PH maturity were comparable and there age at completion of sexual maturation. Subjects and was no statistically significant difference between the . . . controls belonging to higher SECs reached PH5 and two groups (G1: 1 21 versus 0 98; G2: 3 96 versus . . . . . G5 but the number of patients reaching those stages 5 16; G3: 8 09 versus 11 86; G4: 11 48 versus 14 96; . . in the three SECs were quite few, among both G5: 16 12 versus 16 72 all in ml). subjects and controls, as to preclude any further There was a very strong association between the comparison between them. genital stages and TVs of both study groups (Pearson’s . . correlation coefficient, r50 845, P,0 001 for the SCA Testicular volume (TV) . . group and r50 820, P,0 001 for the control group). The mean TVs (Table 4) for controls was signifi- This was also similar for relationship between PH . . cantly higher than for subjects (6 67¡7 2 ml versus stages and TVs for both subjects and controls (r50 903, . . . 3 04¡3 8 ml; P50 0002). The controls attained a TV . . . P,0 001 and r50 809, P,0 001) respectively. . . above 3 ml within the age range 12 0–13 0 years. This Relationship between TVs and socioeconomic status of was earlier than observed among subjects whose . subjects and controls average TV in that age range was 1 70 ml. It is . . Average TVs of subjects were 3 6¡3 8 ml, noteworthy that from age 12 years onwards, the . . . . mean TV of controls were significantly higher than 3 6¡4 6 ml and 3 5¡3 2 ml for upper, middle and those of subjects with (P50 00003). lower SECs respectively. Among controls average . . . . . . Relating the TVs to stages of sexual maturation TVs were 5 8¡7 1 ml, 7 5¡7 1 ml and 6 5¡7 4ml shows that average TV from G1 to G5 for subjects for upper, middle and lower SECs respectively. No . . difference was noticed between mean TVs of subjects and controls were comparable (G1: 0 90 versus 0 94; . . . . . from the different SEC. ANOVA (Table 5) shows G2: 3 1 versus 3 94; G3: 6 37 versus 9 59; G4: 10 81 . . there was no significant difference in the variation of versus 14. 23; G5 16 12 versus 16 17 all in ml) and there was no significant difference between TVs at all the TVs both between and within the various SECs of Table 4 Mean testicular volumes of subjects and controls by age range Subjects Controls 3 3 Age range (years) No. (%) Vol. (SD) in cm No. (%) Vol. (SD) in cm t-test P value . . . . . . . . . . 6 0–7 0 17 (17 0) 0 51 (0 3) 18 (17 8) 0 62 (0 2) 21 170 0 301 . . . . . . . . . . 8 0–9 0 13 (13 0) 0 77 (0 4) 14 (13 9) 1 06 (0 7) 21 374 0 149 . . . . . . . . . . 10 0–11 0 16 (16 0) 0 91 (0 4) 17 (16 8) 1 52 (1 8) 21 342 0 210 . . . . . . . . . . 12 0–13 0 18 (18 0) 1 70 (0 6) 20 (19 8) 5 06 (3 0) 24 837 0 00003* . . . . . . . . . . 14 0–15 0 19 (19 0) 4 17 (2 2) 16 (15 8) 13 96 (3 2) 210 680 0 00001* . . . . . . . . . . 16 0–17 0 15 (15 0) 8 58 (4 2) 13 (12 9) 17 92 (2 4) 27 371 0 00002* . . . . . . . . . 1802(2 0) 16 11 (1 3) 3 (3 0) 21 96 (1 0) 25 882 0 011* . . . . . . . . Combined 100 (100 0) 3 04 (3 8) 101 (100 0) 6 67 (7 2) 24 445 0 0002* *Statistically significant. 418 Hematology 2010 VOL 15 NO 6 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia . . SCA children (F51 148; P50 321). Similarly the respect to completion of sexual maturation when differences between the mean TVs of controls from compared with their normal controls. Whereas the the three different SECs was not significant SCA patients attained both final genital and pubic . . . . (F50 356; P50 701). hair maturity status at 18 0¡0 0 years, their counter- . . . . Since puberty (sexual maturation) is recognized parts did so at 15 9¡1 6 years and 16 3¡1 6 years when G2 is achieved, we conducted a subgroup respectively. This is again similar to the pattern analysis of only the children who had commenced reported by Ozigbo and Nkanginieme with mean . . . . puberty and onwards, i.e. from G2 to G5. There were ages of 18 7¡0 6 years and 19 0¡0 0 years for G5 9, 14 and 20 respectively from the upper, middle and and PH5 respectively. lower SECs among the SCA subjects with mean TVs There is however a reasonably wide difference . . . . . . of 6 3¡3 9, 6 8¡5 2 and 5 0¡4 3 ml. Analysis of between the mean age of onset of sexual maturation variance of mean TVs within and across the three in this present study and that reported by some SECs of SCA patients also showed no significant workers who documented a subnormal pubic hair difference between the mean TVs of the 3 SECs (sum growth pattern in male SCA patients even up to a . . . . of squares5797 942; df542; F-test50 727; P50 490). mean age of 26 6 years. The latter finding has been Similarly, excluding controls below G2 stage, there criticized as a possible reflection of the fact that the were 17, 20, and 30 from upper, middle and lower workers may have had a bias of great interest in . . SECs and their mean TVs were 6 8¡7 3 ml, hypogonadism and thus may have used a group of . . . . 17 11 1¡6 4 ml and 10 1¡7 6 ml respectively. more severely affected patients. In the current ANOVA analysis showed no significant difference study, the first noticeable sign of sexual maturation between the various SECs (sum of squares53537 556; was genital development (G2) but this was closely . . df566; F-test51 844; P50 166). followed by pubic hair development (PH2) and this pattern was maintained for each successive pairs of Discussion stages of development and this agrees with the findings from other studies involving SCA This study demonstrated that a significant delay in 16,17,22 patients and those with normal geno- commencement of pubic hair and genital develop- 7,12,23,24 type. Perhaps the first demonstration of the ment characteristic of puberty still exists among effect of higher socioeconomic class on SCA in our children living with SCA. This is in keeping with 16–18 study population is the relatively fewer number of several earlier studies both from within and 19–21 . . outside Nigeria. The mean age of 14 7¡1 5 years children from the upper class among those seen at the for G2 among our subjects compares remarkably to clinic. The possibilities are that those of higher educational level have learnt to take steps to avoid that by Ozigbo and Nkanginieme among similar having children with SCA leading to a relatively patients from other parts of Nigeria with a mean of . . lower prevalence of the disease among people of 14 6¡1 4 years. Similarly, the mean age for attain- . . higher socioeconomic class. Individuals with higher ment of PH2 (15 5¡1 5 years) is comparable to . . level of education are more likely to be aware of the 14 7¡1 3 years documented in the Port-Harcourt 17 18 series but much lower than that of Oyedeji who need for pre-marital genotype testing and the need to reported the earliest age of pubic hair development in avoid getting into a marriage that will lead to having males to be 20 years. It is noteworthy that Oyedeji children with SCA. Another possible reason is that had only six males aged 13 years and above in his those with better financial status will seek care in study population and most likely, this may have private hospitals which are relatively costlier to limited the findings of his study. Sickle cell anaemia afford compared with government hospitals like patients also demonstrated a significant delay with ours, hence the fewer numbers presenting to us. Table 5 ANOVA of mean TVs for subjects and controls among the three socioeconomic classes Subject (SCA) Controls Sum of Mean Sum of Mean squares df squareFP value squares df squareFP value . . . . . . . . Between groups (SEC) 33 042 2 16 521 1 148 0 321 Between groups (SEC) 37 766 2 18 883 0 356 0 701 . . . . Within groups (SEC) 1395 687 97 14 389 Within groups (SEC) 5196 341 98 53 024 . . Total 1428 729 99 Total 5234 107 100 Hematology 2010 VOL 15 NO 6 419 Uchendu et al. Sexual maturation of Nigerian boys with sickle cell anaemia Children from the upper socioeconomic class status seen among SCA patients may derive from the showed features of sexual maturation before those of fact that most of them are typically very lean and this the other classes. Thereafter, those from the middle may translate into an overtly similar pattern of sexual class followed and the patients from the lower socio- maturation irrespective of social status of patients. economic class were last to show any features of sexual The failure to detect any statistically significant development. This pattern applied to both subjects difference between the three SECs may also be due to (SCAs) and controls (non-SCAs). A similar trend was the classification method used The method of social observed with respect to the completion of sexual classification applied uses a combination of mater- maturation. However, these differences were less nal and paternal educational level and occupational apparent with completion as against commencement to assign SECs. However, it does not determine the of sexual maturation. This trend on the influence of exact expenses on health needs of the family. Also the socioeconomic status on sexual maturity pattern few numbers of patients within some of the classes agrees with conclusion also reached by Adediran may have affected the power of the study to detect on a population of normal schoolboys without SCA in any differences between them. Enugu. Furthermore, the difference is more pro- The mean TVs of SCA patients were lower than nounced between the extremes of the social classes, those of the controls throughout all age groups but that is, between upper and lower classes. this was only noted to be statistically significant . . Higher socioeconomic status implies higher educa- among those who were 12 0–13 0 years old, at which tional level and better financial empowerment and point the controls had reached G2. Both study hopefully translates to the ability of caregivers to seek groups had achieved TVs of at least 3 ml at 5,29 for early and appropriate medical intervention, commencement of puberty. Earlier workers had understand the need and means for preventive reported that increase in TV to 3 ml or more is the measures, and engage in judicious utilization of best marker for puberty and some feel that the resources to take care of family needs. Thus, children initial phase may be missed if TV is not assessed. This from higher socioeconomic classes are more often shows that TV size of at least 3 0 ml is a good better nourished than their poorer counterparts. It is indicator of onset of puberty for both subjects and expected that children of parents from higher socio- controls. Our data validate this especially with the economic classes would demonstrate better growth demonstration of a very strong association between and development pattern. the various stages of genital and pubic hair develop- ment and average TVs of both subjects and controls The population variation in commencement and on the other hand with very high correlation progression of sexual maturation is thought to be highly related to somatic growth or energetic status coefficients. The tendency for children of higher 25,26 and independent of genetic factors. Expectedly SECs to have larger TVs is noted but the lack of any children of higher socioeconomic status are better statistically significant difference between the mean nourished and tend to have higher energy reserves or TVs of the various socioeconomic classes for both lean body mass. This underlies the effect of socio- subjects and controls is in keeping with the pattern economic status on sexual development with children for Tanner staging. This again suggests that socio- from higher classes performing better than those of economic status may only have minimal effect on lower classes as was marginally demonstrated in our sexual maturation of children with sickle cell study groups. Although the differences were not anaemia. However, we encourage caution with the statistically significant between all classes, the pattern interpretation of this data. 17–22,26,27 was too consistent to be ignored. However, the fact Incidentally, none of the several other studies that the difference was not statistically significant evaluated the influence of socio-economic status on may suggest that the negative impact of the disease sexual maturation of SCA patients, thus making it overshadowed whatever impact social class may difficult to compare current findings with other studies ordinarily have had on the patients. Among SCA in this regard. There is, however, a well established trend patients it has been recognized that assessment of among children with normal genotype in whom it is growth using body mass index is a better indicator of shown that children from more developed Western body size rather than height or weight alone. And countries have earlier onset of sexual development using body mass index it is recognized that leanness is compared with those from poorer nations. This evidence 27,28 characteristic of SCA patients. 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Journal

Hematology Online – Taylor & Francis

Published: Dec 1, 2010

Keywords: SEXUAL MATURITY; SICKLE CELL ANAEMIA; TESTICULAR VOLUME; SOCIOECONOMIC STATUS

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