1. Hypoglycemia and Diabetes
Prof. Abdulmoein Al-Agha, MBBS, DCH, CABP, FRCPCH (UK) Consultant, Pediatric Endocrinologist,
King Abdulaziz University Hospital, Jeddah

2. Definition
There is no agreed definition of hypoglycemia
Precise definition remains controversial
It is advisable to maintain blood glucose values above 4.0 mmol/L (70mg/dl) in children & adolescents with diabetes
Hypoglycemia may be symptomatic or asymptomatic (hypo unawareness)

3. Normal & target blood glucose ranges
Normal blood glucose levels in people who do not have diabetes
Fasting: 70 – 110 mg/dl
After meals: up to 140 mg/dl
Target blood glucose levels in people who have diabetes
Before meals: mg/dl
2 hours post meals: < 180 mg/dl
Hypoglycemia: 70 mg/dl or less(4mmol)

4. Glucagon & adrenaline are rapid-acting counter-regulatory hormones
Counter-Regulatory Responses to Hypoglycemia & Hypoglycemia Unawareness
Glucagon & adrenaline are rapid-acting counter-regulatory hormones
When hypoglycemia is prolonged, growth hormone & cortisol are released
The integrity of glucose counter-regulation is disturbed by type 1 diabetes with time
In diabetic subjects glucagon & adrenaline responses to insulin-induced hypoglycemia are characteristically lost

5. Symptoms of Hypoglycemia
Neurogenic (autonomic)
Neuroglycopenic
Trembling
Difficulty Concentrating
Palpitations
Confusion
Sweating
Weakness
Anxiety
Drowsiness
Hunger
Vision Changes
Nausea
Difficulty Speaking
Dizziness

6. Symptoms hunger nervousness & shakiness perspiration
dizziness or light-headedness
sleepiness
confusion
Constant Fatigue
Mood Swings
Irritability
difficulty speaking
Hypoglycemia can also happen while sleeping:
cry out or have nightmares
find that pajamas or sheets are damp from perspiration
feel tired, irritable, or confused when wake up

7. Severity of Hypoglycemia
Mild
Autonomic symptoms present
Individual is able to self-treat
Moderate
Autonomic and neuroglycopenic symptoms
Severe
Requires the assistance of another person
Unconsciousness may occur
Plasma glucose is typically <2.8 mmol/L

8. Causes of Hypoglycemia
The most common causes of hypoglycemia are:
Inadequate or missed meals or snacks
Excessive physical activity (unplanned or more prolonged than usual)
Insulin administration errors (e.g. inadvertent reversal of morning and evening doses)
Vomiting and diarrhea
Other medical problems (Addison’s disease, Celiac disease)
Unknown cause

9. Partial Remission or Honeymoon Phase
In approximately % of children & adolescents, insulin requirements decrease transiently following initiation of treatment
Most studies define partial remission phase as that when the patient requires < 0.5 units of insulin/ kg body weight/ day and has HbA1c <7%
The partial remission phase commences within days or weeks of the start of insulin therapy & may last for weeks to months
Frequent hypoglycemia attacks happen in this period
During this phase blood glucose levels are frequently stable within the normal range, despite fluctuations in diet and exercise
As low dose subcutaneous insulin therapy does not prolong residual beta cell function

10. Somogyi Phenomenon
Hypoglycemia causing rebound hyperglycemia referred to as Somogyi phenomenon
Fasting hyperglycemia due to counter-regulatory overshoot of blood glucose following unrecognized nocturnal hypoglycemia
Whilst the Somogyi phenomenon has been shown to exist, the dawn phenomenon and the waning of insulin levels are more likely causes of Fasting hyperglycemia

11. Prevention Advices to the child with Diabetes:
Check blood sugar regularly & whenever symptoms of hypoglycemia occur
know what causes hypoglycemia (missing meals, snacks, exercise …..etc)
know the symptoms of hypoglycemia & checking glucose readings immediately
carry glucose tablets or hard candy at all times
wear medical ID bracelet or diabetic ID card
let friends, co-workers, or family members know how to give an injection of glucagon
eat full meal at regular times; do not skip meals or eat partial meals
Extra snack prior of exercise

12. Diabetes Bracelet

13. Hypoglycemia in School
Teachers at schools should be informed about symptoms of hypoglycemia & appropriate treatment
It may be useful for member of the diabetes team to visit the school & provide education to the teachers
Children should not be restricted in activities at school but extra carbohydrate should be given prior to sports & physical activities
Easily absorbed carbohydrate should be available at school as well one kit of Glucagon injection

14. Treatment

15. Mild to moderate hypoglycemia
Immediate consumption of 15 gm of simple form of carbohydrate
15 g of glucose in the form of glucose tablets
15 mL (3 teaspoons) or 3 packets of sugar dissolved in water
120 mL (1/2 cup) of juice or regular soft drink
6 Lifesavers (1=2.5 g of carbohydrate)
15 mL (1 tablespoon) of honey
Followed by snack of carbohydrate foods to maintain normoglycaemia until the next meal or snack
Insulin & dietary adjustments should be made to prevent further hypoglycemia when appropriate

16. Important Notice
Many people like the idea of treating hypoglycemia with cake, cookies, and brownies.
However, sugar in the form of complex carbohydrates or sugar combined with fat and protein are much too slowly absorbed to be useful in the acute treatment of hypoglycemia
Once the acute episode has been treated, healthy, long-acting carbohydrate to maintain blood sugars in the appropriate range should be consumed e.g. Half sandwich is reasonable option

17. Severe Hypoglycemia For severe hypoglycemia therapy is urgent
People who are either unconscious, fitting are unable to swallow
Nothing should be given by mouth
The airway should be checked to ensure that respiration is unhampered, the person should be placed on their side (resuscitation position) to prevent aspiration of material into the lungs and emergency services
Parents are taught to administer glucagon by injection (s.c., i.m. or i.v.)
0.5 mg <8 years of age or <25kg,
1.0 mg >8 years of age or >25kg.
If no response in 10 minutes, check blood glucose. If still low repeat once
Follow-up with carbohydrate foods and frequent monitoring.
In hospital: intravenous dextrose (2-5 ml/kg of 10% dextrose), followed by 5-10% dextrose infusion to maintain blood glucose level between 5-10 mmol/L

18. Glucagon Kit for Treatment of Hypoglycemia

19. Insulin Adjustment Depend on insulin regimen
Depends on type of insulin used
Other factors are involved
Time of hypoglycemia
Single attacks Vs Repeated
Total insulin daily dose
Rule of thumb: adjustment of the dose 10-20% of total daily dose

20. Insulin Adjustment If hypoglycemia happens in:
Pre BF ---- adjust night intermediated /long –acting insulin
Pre-Lunch --- adjust morning short / Rapid acting insulin
Pre-Dinner --- adjust morning intermediate –acting or Lunch short acting insulin
Pre-Bed --- adjust evening short/ rapid acting insulin

21. Recommendations & Principles
Hypoglycemia is the most frequent acute complication of type 1 diabetes
Severe hypoglycemia should be avoided in children, especially in those less than 5 yrs
Blood glucose values should be maintained above 4.0 mmol/L (70 mg/dl) in children & adolescents with diabetes
Children & adolescents with diabetes should wear some form of identification or warning of their diabetes
All children & adolescents with diabetes should carry glucose tablets or readily absorbed carbohydrate and have glucagon available at home

22. Recommendations & Principles
Hypoglycemia in children is largely preventable; however there is a significant proportion of severe hypoglycaemic episodes in which no obvious cause can be determined
School teachers and carers at schools should be informed of the symptoms and appropriate
treatment of hypoglycemia and should have access to advice when necessary.
In the hospital setting severe hypoglycemia should be treated with intravenous dextrose
The recommended dose of intravenous dextrose is 2-5ml/kg of 10% dextrose
50% dextrose should not be used
Intramuscular or subcutaneous glucagon is an effective way of treating severe hypoglycemia in a home-care setting

23. Thanks شكرا" لكم