Hypoglycaemia: symptoms, treatment and prevention

By Cristiano Antonino On Nov 4, 2022

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What is hypoglycaemia? In theory, hypoglycaemia is ‘the glycaemic level at which neurological dysfunction begins’

But this level

varies from one person to another;
can vary with time and circumstances;
is conditioned by previous hypoglycaemias.

In practice, hypoglycaemia causes signs and symptoms of:

Neuroglycopenia (impaired thinking, altered mood, irritability, dizziness, headache, fatigue, confusion to convulsions and coma);
The glycaemic threshold of cognitive impairment is usually between 54 and 63 mg/dl (plasma glucose 63 ? 72)
Autonomic activation (hunger, shaking of hands and legs, palpitations, anxiety, pallor, sweating);

Blood glucose threshold for activation (counter-regulatory)

It is often at higher blood glucose levels in children than in adults;
Varies with level of metabolic control;
Poor control and higher blood glucose thresholds;
Good control and lower blood glucose thresholds;
Can be lowered by previous hypoglycaemias;
Altered by sleep.

Therefore loss of consciousness may occur before autonomic activation (= Hypoglycaemia without warning [hypoglycaemia unawareness]).

Degree of severity of hypoglycaemia

According to the level of severity, a distinction is made between:

Mild or 1st degree hypoglycaemia: The child or adolescent is alert, responsive and able to treat hypoglycaemia independently

(N.B. Slight hypoglycaemia as they are not usually able to manage it on their own)

Moderate or 2nd degree hypoglycaemia: The child or adolescent cannot respond to hypoglycaemia and requires help from others, but oral treatment is sufficient.

Severe or Grade 3 hypoglycaemia: The child or adolescent is semi-conscious or unconscious or in a coma and may require parenteral therapy (glucagon or e.v. glucose).

What are the predisposing factors for hypoglycaemia?

Hypoglycaemia is the result of an incorrect balance between insulin, diet and exercise.

There are, however, some predisposing factors such as:

Altered habits (missed or incorrect meals, changes in physical activity, changes or errors in insulin dosage or absorption);
Young age
Low HbA1c;
Total insulin insufficiency;
Previous hypoglycaemic episodes;
Defective glucagon and catecholamine counter-regulation (longer duration);
Alcohol ingestion;
Hypoglycaemic unawareness.

Exercise and hypoglycaemia

Muscle activity can lower blood glucose during, immediately after and/or hours after exercise.

The effects of hypoglycaemia are extremely variable and its severity depends on many factors.

Recommendations for the individual person can only be made on the basis of age, build, individual experience and ‘trial and error’.

Specifically in the combination of exercise and hypoglycaemia, a distinction can be made between:

Light or sporadic exercise

A small intake of rapidly absorbed carbohydrates immediately before exercise is usually recommended.

Intense, strenuous and/or prolonged exercise

A reduction in insulin may be considered;

Extra carbohydrate intake is needed especially before going to bed after afternoon or evening exercise (a night snack also containing fat and protein can help prevent night-time hypoglycaemia).

High-risk sports activities where hypoglycaemia can be potentially dangerous (e.g. water sports, climbing, skiing, fast driving, etc.)

The goal of achieving normoglycaemia may be temporarily relaxed;

Fast-absorbing carbohydrates must be made readily available;

A decrease in the insulin dose may be considered;

Late and/or nocturnal hypoglycaemias may be prevented by a focus on increasing snacks, especially before bedtime.

Only subsequent blood glucose monitoring will make it possible to gain experience of glycaemic levels during and after exercise and sport and thus to develop personalised algorithms.

How to prevent hypoglycaemia?

In any case, it is advisable to act according to a preventive logic based on the following points:

Education of young people, their relatives and carers with special attention to:
Early warning signs and symptoms;
Effect of exercise;
Management of episodes;
Review of education.

Evaluation of episodes, particularly

Food intake (snack before bedtime, pre- and post-exercise carbohydrate intake);
Insulin profile (fast-acting insulin may reduce postprandial or nocturnal hypoglycaemia; separate administration of the evening premix may be considered, detaching the preprandial rapid from the intermediate before bedtime);
Night-time (2.00-4.00) blood glucose measurements.

Revision of glycaemic control targets for people at high risk (e.g. small children and those with ‘unawareness’).

Treatment of hypoglycaemia

The treatment of hypoglycaemia varies, of course, according to the type of attack:

Mild or moderate (1st or 2nd degree)

Immediate ingestion of rapidly absorbed simple carbohydrates e.g. 5-15 g glucose (sugars), 100 ml sweet drinks (fruit juice, Cola etc.)

Wait 10-15 minutes; if there is no improvement, ingest an equal or greater amount of carbohydrates.

As soon as symptoms begin to subside or blood sugar levels return to normal, complex carbohydrates (such as fruit, bread, cereals, milk) should be ingested.

Severe (3rd degree)

Urgent treatment

Severe hypoglycaemia with loss of consciousness and convulsions (particularly in the presence of vomiting) must be reversed definitely and quickly by injection of Glucagon.

If Glucagon is not available or the amount is insufficient, intravenous Glucose at a dose of 200-500 mg/kg (e.g. Dextrose 10% is 100mg/ml) can be administered slowly over several minutes by trained personnel to combat hypoglycaemia.

If the hypoglycaemia is not severe enough to prevent swallowing, salivation or induce vomiting, it is common practice to instruct parents and caregivers to administer concentrated sugar syrup, candy, honey or jelly by placing it between the cheek and gums to allow the glucose to be absorbed through the mucosa of the mouth.

Massaging the cheek externally facilitates glucose absorption, it is not an invasive method and some of the sugar may be digested and absorbed in the lower gastrointestinal tract.

In the improvement phase after severe hypoglycaemia, the child can take

an oral carbohydrate supplement;
an intravenous infusion of glucose, about 5 mg/kg/minute.

N.B.: Strong doses of intravenous hyperosmolar glucose must be administered with great caution to avoid cerebral oedema;

Careful observation and monitoring of blood glucose after severe and prolonged hypoglycaemia is essential as vomiting is common and recurrent hypoglycaemia may occur.

In any case, however, great care must be taken to prevent hypoglycaemia, especially in young children, as the consequences may include developmental delays and hence brain dysfunction.

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