Treatment of Hypoglycemia in Children/Teens

This section copied major portions (with the only addition being the inclusion of adults in the advice) from: The Diabetes in Children and Adolescents Management Guidelines Manual, 2003; "Hypoglycemia" Section, 2nd Edition, prepared for Nova Scotia Diabetes Centres, by The Diabetes in Children and Adolescents Subcommittee, Chaired by SR Salisbury MD,FRCPC, Medical Director, Diabetes Care Program of Nova Scotia, Halifax, NS. The project was funded by the Nova Scotia Department of Health. For copies of the Manual contact: The Diabetes Care Program of Nova Scotia, 1278 Tower Road, Bethune Building- Suite 577, Halifax, NS, B3H 2Y9; 902 473 3219; dcpns@diabetescareprogram.ns.ca; www.diabetescareprogram.ns.ca

See also CDA 2003 Clinical Practice Guidelines: Hypoglycemia



A. Glucagon

  1. Give Glucagon intramuscularly or subcutaneously in the arm, leg, abdomen, or buttocks.11-12
  2. Dose
    • 0.5 mg if < 20 kg (44lb) or < age 5 years
    • 1 mg if > 20 kg (44lb) or > age 5 years 4,11-12
  3. Response should be within 5 to 20 minutes When the child/adolescent/adult is regaining consciousness (and seizures if any have stopped), an easily swallowed glucose/glucose source1 or a glucose gel product (e.g., Cake Mate®, Dec A Cake®, Instaglucose®, etc.) may be given.4, 7
  4. When the child/adolescent/adult is alert, give 10 to 15 g CHO (See Table 1).1
  5. If a meal or snack is not scheduled within the next 30 minutes, give a snack containing significant CHO (at least 30 to 60 g CHO) to replenish glycogen stores.
  6. Family/caregiver(s)/friends should notify a member of the diabetes team or emergency services to discuss the episode. It may be necessary for the child/adolescent/adult to be seen immediately following successful treatment of severe hypoglycemia.1
  7. Perform SBGM within 15 minutes after treatment of a conscious person or after the administration of glucagon,1 again in 2 hours, and then as necessary. The blood glucose should be maintained above 6 mmol/L.2
  8. Once hypoglycemia has been treated, the cause of hypoglycemia should be explored. If the cause is not apparent or easily correctable, the insulin dose may need to be adjusted.2,8,12
  9. Glucagon rapidly raises the blood glucose by stimulating glycogenolysis2 which makes it an ideal treatment for use in insulin induced hypoglycemia.
  10. This treatment is to be taught to all caregivers of persons who have Type 1 diabetes and for many who are type 2 on insulin. It is also useful in institutions including emergency departments, particularly if venous access is difficult, or as a standing order for use in emergency if specially qualified caregivers are not immediately available.

Glucagon: instructions for caregivers and for those old enough to instruct companions


B. Intravenous glucose

  1. Dose is 0.5 g/kg over 1 to 3 minutes to a maximum of 25 g intravenously is standard guideline.1
  2. This is standard treatment for emergency for qualified personnel and if IV access not a problem.


C.Oral treatment (rarely feasible for really severe hypoglycemia)

  1. If the person is alert enough to swallow you can give a dose 20 g CHO (Glucose tablets or equivalent are preferred) then wait 15 minutes. Repeat SBGM. Treat again if SBGM is < 4 mmol/L.
  2. Glucose gel or any tablet must be swallowed to have significant effect on the blood glucose level, so oral treatment is less likely to be appropriate in severe hypoglycemia.



Special Considerations: Nocturnal Hypoglycemia and Hypoglycemia Unawareness

Nocturnal Hypoglycemia

Table 1: Equivalents of 10 to 15 g Carbohydrate*
3 to 4 Dextrosol® or DextroEnergyTMtablets
2 to 3 BD® tablets
160 to 250 mL (2/3 - 1 cup) Gatorade®
Cake Mate® gel (20 g package), Dec A Cake® gel
125 mL ( 1/2 cup) regular pop
10 to 15 mL (2-3 teaspoons) sugar
2 to 3 sugar cubes
10 to 15 mL (2-3 teaspoons) pasteurized corn syrup or honey
4 to 6 Lifesavers®
2 to 3 hard candy mints
125 mL (1/2 cup) unsweetened fruit juice, example, McCain's Junior JuiceTM pack
1 package of Insta-glucose (31 g)

* Carbohydrate sources that contain pure glucose are preferred (glucose tablets, regular soft drinks, hard candies). Fruit juice and milk are slower to raise blood glucose levels because fructose and galactose must be converted to glucose in the liver before entering general circulation. Fruit juice and milk are still appropriate for younger children who may not have the feeding skills to chew hard candies or glucose tablets, and soft drinks are generally avoided in the younger years.


Sources:
Canadian Diabetes Association. Good Health Eating Guide. Toronto, ON: Author; 1995.
Pennington J. Bowes & Church's Food Values of Portions Commonly Used. 17th ed. Philadelphia, PA: Lippincott; 1998.
Additional choices include any of the items, in the amounts indicated, from the sugar group on the Good Health Eating Guide, Canadian Diabetes Association, 1994.

References:

1. Yale JF, Begg I, Gerstein H, et al. 2001 Canadian Diabetes Association clinical practice guidelines for the prevention and management of hypoglycemia in diabetes. Canadian Journal of Diabetes Care. 2002;26:22-35.

2. Franz MJ, ed. A Core Curriculum for Diabetes Education. 4th ed. Chicago, IL: American Association of Diabetes Educators: 2001.

3. Toth E. Understanding and managing hypoglycemia. Canadian Journal of Continuing Medical Education. January 2001:113-121.

4. American Diabetes Association. Medical Management of Insulin-Dependent (Type I) Diabetes. 3rd ed. Alexandria, VA: Author; 1998.

5. American Diabetes Association Council on Education. Intensive Diabetes Management. Alexandria, VA: American Diabetes Association; 1995.

6. Franz M. Fuel metabolism, exercise, and nutritional needs in type 1 diabetes. Canadian Journal of Diabetes Care. 1998;22:59-63.

7. Farkas-Hirsch R. All about hypoglycemia. Diabetes Self-Management. 2000;January/February:21-27.

8. Haymond MW, Schreiner B. Mini-dose glucagon rescue for hypoglycemia in children with type 1 diabetes. Diabetes Care. 2001;24:643-645.
9. Gale EAM, Tattersall RB. Unrecognized nocturnal hypoglycemia in insulin-treated diabetics. Lancet. 1979;19:1049-1052.

10. Kalergis M, Schiffrin A, Gougeon R, Jones PJH, Yale JF. Impact of bedtime snack composition on prevention of nocturnal hypoglycemia in adults with type 1 diabetes undergoing intensive insulin management using lispro insulin before meals. Diabetes Care. 2003;26:9-15.

11. Herbes C, Boyle P. Hypoglycemia - Pathophysiology and treatment. Endocrinology and Metabolism Clinics of North America. 2000;29(4):725-743.

12. Eli Lilly Canada Inc. Package insert: Information for the physician on glucagon for injection, USP. Toronto, ON; March 1998. 13. Corry D. Driving, diabetes, and you. Diabetes Dialogue. 1996;Summer:11.

14. Clarke WL, Cox DJ, Gonder-Frederick L, Kavatchev B. Hypoglycemia and the decision to drive a motor vehicle by persons with diabetes. Journal of the American Medical Association. 1999;282(8):750-754.

15. Cox DJ, Gonder-Frederick L, Kovatchev B, Julian D, Clarke WL. Progressive hypoglycemia's impact on driving simulation performance. Diabetes Care. 2000;23:163-170.

16. Begg IS, Yale J-F, Houlden RL, Rowe RC, McSherry J . Canadian Diabetes Association's Clinical Practice Guidelines for Diabetes and Private and Commercial Driving. Canadian Journal of Diabetes 2003;27:128-140.

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