Hypoglycaemia in Diabetics
Hypoglycaemia in Diabetics
General and supportive measures
ICD-10 Code: E16.0
DESCRIPTION
Autonomic symptoms (hunger, nausea, anxiety, pallor, palpitations, sweating, trembling) usually precede neuroglycopaenic symptoms (impaired thinking, change of mood, irritability, dizziness, headache, tiredness, confusion, and later convulsions and coma). Patients with frequent hypoglycaemic episodes develop hypoglycaemia unawareness, where the symptoms above do not occur despite a dangerously low blood sugar level.
Causes of hypoglycaemia include:
- A missed or delayed snack or meal.
- Exercise without appropriate dietary preparation.
- Alcohol.
- Overdose of insulin.
- Impaired food absorption e.g. gastroenteritis.
- Addison’s disease. Recurrent hypoglycaemia may necessitate investigation for this condition.
- Coeliac disease.
Nocturnal hypoglycaemia
Nightmares and headaches may be suggestive of nocturnal hypoglycaemia.
Blood glucose concentrations fall to their lowest levels between 02h00 and 04h00.
DIAGNOSTIC CRITERIA
- Blood glucose < 3.5–4 mmol/L with symptoms in a known diabetic patient. Good glycaemic control is likely to be associated with occasional hypoglycaemic episodes.
- Grading of severity:
- Mild (Grade 1)
- Child or adolescent is aware of, responds to and self-treats the hypoglycaemia.
- Children < 6 years of age can rarely be classified as grade 1 because they are unable to help themselves.
- Moderate (Grade 2)
- Child or adolescent cannot respond to hypoglycaemia and requires help from someone else, but oral treatment is successful.
- Severe (Grade 3)
- Child or adolescent is semiconscious or unconscious with or without convulsions and may require parenteral therapy with glucagon or intravenous glucose.
GENERAL AND SUPPORTIVE MEASURES
- Determine underlying cause.
- Patient education on diabetes and its complications.
MEDICINE TREATMENT
Mild or moderate hypoglycaemia
Immediate oral, rapidly absorbed, simple carbohydrate, e.g.:
- Glucose, oral, 5–15 g or 1-3 level teaspoons of sugar (depending on child's age) in a small amount of water.
- Wait 10–15 minutes.
- If blood glucose has not risen to 3-4 mmol/L, repeat above.
- As symptoms improve, the next meal or oral complex carbohydrate should be ingested, e.g. fruit, bread, cereal, milk, etc.
Severe hypoglycaemia
Outside hospital
- Glucagon, IM/SC.
- If < 12 years of age: 0.5 mg.
- If 12 years of age: 1.0 mg.
If glucagon is not available:
A teaspoon of sugar moistened with water placed under the tongue every 20 minutes until patient awakes.
In hospital
If there is an unsatisfactory response or inability to take oral carbohydrate and signs of disorientation, stupor, convulsions, coma:
- Dextrose 10%, IV, 2–5 mL/kg.
- Dilute dextrose 50% solution to 10% strength before use, i.e. Dextrose 50% 1 mL + water for injection 4 mL = 5 mL 10% dextrose solution.
If IV dextrose cannot be given:
- Glucagon, IM/SC.
- If < 12 years of age: 0.5 mg.
- If 12 years of age: 1.0 mg.
Monitor blood glucose every 15 minutes until stable, then repeat 1–2 hourly.
Keep blood glucose between 6 and 8 mmol/L.
REFERRAL
- Recurrent episodes of hypoglycaemia.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 7: Endocrine, 7.5 Diabetes Mellitus, 7.5.2 Diabetes Mellitus, Insulin Dependent: Acute Complications, 7.5.2.3 Hypoglycaemia In Diabetics