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Cited by 135Diabetes Management and ResearchDiabetes Management and EducationDiabetes and associated disorders

Assessment and management of hypoglycemia in children and adolescents with diabetes

Clarke, William, Jones, Timothy, Rewers, Arleta, Dunger, David, Klingensmith, Georgeanna J·2009·Pediatric Diabetes
DOI 10.1111/j.1399-5448.2009.00583.x
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Abstract

Hypoglycemia is the result of a mismatch between insulin dose, food consumed, and recent exercise and is rarely, if ever, a spontaneous event. A careful review of only blood glucose (BG) records will yield a retrospective prediction of the hypoglycemic event for at least 50% of events (1, 2). Because it can be accompanied by unpleasant, embarrassing, and potentially dangerous symptoms and because it causes significant anxiety and fear in the patient and their caregivers, it's occurrence is a major limiting factor in attempts to achieve near normal BG levels (3, 4). Additionally, in its extreme manifestations, hypoglycemia can lead to permanent sequelae and even death (5–8). Intensive diabetes management initially resulted in a dramatic increase in the rate of hypoglycemia in adolescents (9, 10). Greater experience with intensive therapy and use of analogue insulins decreased the rates of severe hypoglycemia to 8–30 episodes per 100 patient-years of diabetes exposure (11–15), with the exception of very low incidence (,4/100 person-years) in a Finnish study (16). Non-modifiable predictors of severe hypoglycemia are: Age (infancy and adolescence) (11, 14); Increased duration of diabetes (12, 13, 15). Modifiable predictors are: Lower hemoglobinA1c (HbA1c) and Higher insulin dose. Direct health care cost of severe hypoglycemic events is estimated at 7 400 euros per 100 patients per year in the1990s (17). Further studies are needed to update these figures and to estimate, in addition, indirect costs (e.g., lost productivity and diminished quality of life). Hypoglycemia is often accompanied by signs and symptoms of autonomic (adrenergic) activation and/ or neurological dysfunction (neuroglycopenia). Children may also exhibit behavioral or mood changes when their BG falls but remains within or above the normal range (18, 19). Autonomic signs and symptoms Trembling; Pounding heart; Cold sweatiness; Pallor. Neuroglycopenic signs and symptoms Difficulty concentrating; Blurred vision or double vision; Disturbed color vision; Difficulty hearing; Slurred speech; Poor judgment and confusion; Problems with short-term memory; Dizziness and unsteady gait; Loss of consciousness; Seizure; Death. Behavioral signs and symptoms Irritability; Erratic behavior; Nightmares; Inconsolable crying. Non-specific symptoms (associated with low, high, or normal BG) Hunger; Headache; Nausea; Tiredness. There is no consistent or agreed upon numerical definition of hypoglycemia for the child with diabetes. Nevertheless, BG values below 3.3–3.9 mmol/L (60–70 mg/dL) are generally agreed to place the individual at risk for severe hypoglycemia because BG values in this range are associated with alterations in the counterregulatory hormones essential to the spontaneous reversal of hypoglycemia (14, 20, 21). For clinical use, the value of < 3.6 mmol/L (65 mg/dL) has been most often used as the level for defining hypoglycemia in the pediatric population. However, a recent American Association (ADA) Working Group report suggested using 3.9 mmol/L (70 mg/dL) as the definition in all age groups for research purposes in evaluating therapies designed to alter frequency of hypoglycemia (21). Therefore, in the interest of avoiding hypoglycemia and maintaining consistency in reporting hypoglycemia, 3.9 mmol/L (70 mg/dL) is the recommended lower target for BG levels in children and adults with insulin-treated diabetes (14, 21). Alterations in activation of autonomic symptoms or neuroglycopenia (cognitive dysfunction) have been documented to occur at BG levels as high as 3.6 mmol/L (22). However, the absolute BG level at which signs and symptoms begin to occur may vary among individuals and within the same individual at different times and in different situations (23). Young children and their parents are not as accurate at recognizing early warning signs and symptoms of low BG, as are adults with diabetes (24). Therefore, frequent BG monitoring should be encouraged especially during times at which extreme BG levels might be anticipated (overnight, at the peak of insulin actions, during and after strenuous exercise, when insulin doses are adjusted, during stressful situations, during illnesses, etc.). The BG threshold for activation of autonomic signs and symptoms is related to activation of counterregulatory hormones and has been shown to be higher in children than in adults and to vary directly with the level of BG control (higher HbA1c, higher BG threshold) (14, 25). The BG threshold for symptoms may be affected by antecedent hypoglycemia or hyperglycemia (26). This may be accompanied by reduced intensity of symptoms over 24 h following a hypoglycemic event, leading to reduced awareness of hypoglycemia during this time. Low or moderate exercise one day may result in a decrease in symptoms of hypoglycemia and decreased hormonal reactions the next day (27). Also, the BG threshold is reduced during sleep (28, 29). The BG threshold for neuroglycopenia neither v

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Authors
Clarke, W., Jones, T., Rewers, A., Dunger, D., & Klingensmith, G. J.
Affiliations
  • University of Virginia (US)
  • Princess Margaret Hospital for Children (AU)
  • University of Colorado Denver (US)
  • University of Cambridge (GB)
Corresponding author
Clarke, William
ORCID
Venue
Pediatric Diabetes
Publisher
Wiley
Published
2009-09
Volume
10
Pages
134-145
ISSN
  • 1399-543X (ISSN-L)
  • 1399-5448
DOI
10.1111/j.1399-5448.2009.00583.x
OpenAlex
W4241342988
Cited by
135
References
108
Citations by year
2026: 2 · 2024: 2 · 2023: 3 · 2022: 3 · 2021: 11 · 2020: 5 · 2019: 7 · 2018: 10 · 2017: 11 · 2016: 8 · 2015: 12 · 2014: 20 · 2013: 14 · 2012: 10
FWCI
1.18
Type
journal article
Language
en
Open access
closed
Licence
doi.wiley.com/10.1002/tdm_license_1.1 (tdm, 2191 d)
Locations
Pediatric Diabetes (publishedVersion)
Funders
National Institute for Health and Care Research (NF-SI-0508-10274)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
Keywords
hypoglycemia, adolescent diabetes, severe hypoglycemia, hypoglycemia management, hypoglycemia prediction, blood glucose monitoring, insulin dose, HbA1c, hypoglycemia risk factors, neuroglycopenia, autonomic symptoms, behavioral symptoms, hypoglycemia awareness

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