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Child Health Guideline Identifier

Diabetes - managing hypoglycaemia in hospitalised patients with diabetes mellitus

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Background

Hypoglycaemia occurs when the blood glucose level is less than 4 mmol/L, or where symptoms of hypoglycaemia are experienced at a blood glucose level close to this.

Hypoglycaemia is graded as mild, moderate or severe.

When hypoglycaemia is recurrent, it is important to exclude co-existing autoimmune disorders such as thyroid disease, Addison's disease, and coeliac disease.

Causes of Hypoglycaemia

The main causes of hypoglycaemia are:

  • Excessive insulin dosing
  • Missed or delayed meals, or eating too little carbohydrate at meals
  • Exercise, without decreasing the insulin or without eating additional carbohydrate
  • Concurrent illness causing vomiting and/or diarrhoea
  • Alcohol intake

Management of hypoglycaemia

The aim of hypoglycaemia treatment is to:

  • Restore euglycaemia (4-7mmol/L)
  • Prevent progression to severe hypoglycaemia

Treatment Algorithm for mild-moderate hypoglycaemia in patients with type 1 diabetes mellitus

Hypo flow chart

The amount of glucose required to treat hypoglycaemia depends on:

  • body size
  • type of insulin therapy
  • active insulin on board, and
  • The timing and intensity of antecedent exercise/activity.

Treatment is urgent.

Examples of fast acting carbohydrate include:

  • HypoPak
  • 125 mL pre packed "Twist™" juice drink
  • 10 - 20 g of glucose tablets. La Vita glucose tablets contain 3.1 g glucose/tablet. (Tablets are not suitable for children under 5 years)

Chocolate, milk, and other foods containing fat will cause glucose to be absorbed more slowly and should be avoided as the initial treatment of hypoglycaemia.

Examples of slow acting carbohydrate include:

  • 1 slice of bread
  • 200 mL milk
  • 6 small dry crackers or 2 large dry crackers
  • An apple
  • A banana
  • Bring next scheduled meal forward in place of snack if due within half an hour

Night hypoglycaemia

Hypoglycaemia at night is more likely to occur after increased levels of activity during the day or if a child/adolescent has eaten poorly or is unwell. Hypoglycaemia at night can occur in the period following initial diagnosis when insulin dose requirements are still being assessed. Seizures associated with hypoglycaemia at night are a risk.

The risk of night hypoglycaemia can be minimised as follows:

  • Target blood glucose level at suppertime/bedtime 6 to 10 mmol/L (6 -12 mmol/L in infants or children under 5 years). If less than 6 mmol/L an additional 5 - 20 g of carbohydrate should be added to the supper carbohydrate allowance
  • Blood glucose level checked at midnight and again at 0400 or as ordered by the medical team.

Hypoglycaemia unawareness

Impaired hypoglycaemia awareness and hypoglycaemia associated autonomic failure (HAAF) may develop in children and adolescents and should be considered in patients who experience recurrent hypoglycaemia.

Hypoglycaemia unawareness is where hypoglycaemia is occurring as measured by blood glucose test or observed by others but the child with diabetes remains unaware.

Awareness of hypoglycaemia in toddlers and babies and children with special needs who developmentally are unable to verbalise, relies solely on others. Newly diagnosed children and young people may also have difficulties recognising and verbalising symptoms of hypoglycaemia. Children need to be supported to learn how to recognise and verbalise hypoglycaemia symptoms in order to seek appropriate support with treatment.

Hypoglycaemia unawareness can develop following frequent hypoglycaemia episodes. It is associated with a significantly increased risk of severe hypoglycaemia. Impaired awareness may be corrected by avoidance of hypoglycaemia.

Information for Families

What you need to know about Hypoglycaemia Online Teaching Module

References

  1. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. - Hypoglycemia: Assessment and management of hypoglycemia in children and adolescents with diabetes. Ly, T.T., Maahs, D.M., Rewers, A., Dunger, D., Oduwole, A., & Jones, T.W. Pediatric Diabetes 2014: 15 (Suppl. 20): 180-192.
  2. National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes in Children, Adolescents and Adults Craig, ME, Twigg, SM, Donaghue, KC, Cheung, NW, Cameron, FJ, Conn, J, Jenkins, AJ, Silink, M, for the Australian Type 1 Diabetes Guidelines Expert Advisory Group. Australian Government Department of Health And Ageing, Canberra 2011.

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Document Control

  • Date last published: 08 June 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Endocrinology
  • Author(s): Rosalie Hornung, Fran Mouat, Craig Jefferies
  • Owner: Paediatric Diabetes Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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