Hypoglycaemia or a ‘hypo’ occurs when the blood glucose level (BGL) drops too low. Usually this occurs when the BGL is less than 4mmol/L. In children under 5 years of age, a BGL under 5mmol/L should be treated as a hypo. Where there are symptoms at a level close to this, it should also be treated as a hypo.

What are the main causes of hypoglycaemia?

Hypoglycaemia can be caused by a number of different things and/or a combination of these:
• Physical activity
• Delayed or missed meal / snack
• Not eating enough carbohydrate
• Too much insulin
• Variable insulin absorption
• Infections causing nausea, vomiting and/or diarrhoea
• Alcohol consumption
Sometimes a hypo can occur for no obvious reason.

Signs and symptoms

While signs and symptoms vary from child to child, you or your child may notice one or more of the following:
• Weakness
• Trembling
• Shaking
• Paleness
• Dizziness
• Sweating
• Behaviour change – tearful, irritable
• Confusion
• Lack of concentration
• Headache
• Hunger
• Heart pounding
• Numbness around lips and fingers

Each child is different and symptoms may not always be the same, some children may not recognise their hypo symptoms, particularly if they are young. Occasionally children may mistake high blood glucose levels as a hypo, as the symptoms can be similar.

The symptoms of a hypo occur when the body produces hormones such as adrenaline to counteract the low blood glucose and as a result of brain not getting enough glucose to function normally.

Preventing hypos

Hypos cannot always be prevented, however ensuring the following may help:
• Regular carbohydrate containing meals and snacks as suggested by your diabetes team (up to every 2-3 hours depending on your child’s insulin plan)
• Correct dose of insulin given at right time of day
• Insulin adjustment and extra carbohydrate foods for sport & excursions
• Rotating injection sites
• BGL above 7mmol/L at bedtime
• Additional carbohydrate foods with alcohol

Treating hypos

Depending on the severity of symptoms and the blood glucose level, hypos can be classified as mild, moderate or severe.

Mild / moderate hypos

A mild or moderate hypo is when the child is conscious and able to take direction to treat the hypo. If you suspect BGL is low and your child has obvious symptoms, commence treatment immediately. Test BGL as the hypo is being treated.

How to treat a mild / moderate hypo:

1. Give any one of the following easily absorbed carbohydrates:

• 125 – 200ml fruit juice (1 small tetra pack) or
• 1/3 – ½ can regular (sugar containing) soft drink or
• 3 teaspoons honey or sugar or
• 4 large or 7 small jelly beans or
• Glucose tablets – check packet for carbohydrate content as they vary

2. Follow-up with a snack or meal if due within 10 minutes, if not, give a longer lasting carbohydrate such as:

• A piece of fruit or
• A slice of bread or
• Two plain sweet biscuits or
• A glass of milk

Do not give anything by mouth if there is any doubt about the child’s ability to swallow.

Recovery:
• The child will usually feel better after 10-15 minutes, however it may take longer (ie. 15-20 minutes) to see a measurable rise in BGLs. If they don’t respond within this time, repeat the first step of the hypo treatment.

• Hypos can have a significant effect on a child’s ability to concentrate, which may last for several hours afterwards.

Severe hypos

A severe hypo is when the child is extremely drowsy, unable to take direction, unconscious and/or having a fit or seizure.

How to treat a severe hypo:

1. Place the child in the recovery / coma position (on their side, making sure their airway is clear)

2. Remove any danger / obstacles that can harm the child

3. Call an ambulance and state “diabetes emergency”

4. If available, give a glucagon injection – this is a hormone that makes the stored glucose be released from the liver to raise BGL.

Always discuss a severe hypo with your diabetes team.

Recovery:
• Following the treatment of a severe hypo, a child will usually wake in 5-10 minutes. Following glucagon, a headache and / or vomiting are common. As the child is recovering, encourage small amounts of regular soft drink or another sweet drink. Follow this with longer lasting carbohydrate to keep BGLs from dropping low again.

• Monitor BGLs at least every 30 minutes following a severe hypo.

• Do not omit the usual insulin after the hypo, seek medical advice about the dose. High BGLs after a severe hypo should not be treated with extra insulin.

• Contact your diabetes doctor or educator if vomiting persists and for advice on subsequent insulin dosage.

• Take you child to the emergency department of your closest hospital is your child’s condition does not improve.

Glucagon

Glucagon is a medication given by an injection into the muscle and is used to treat severe hypoglycaemia when the person with diabetes is unable to take anything to eat or drink by mouth. It is a hormone that makes the liver release its stored glucose to raise the blood glucose level. All families should have Glucagon at home and know how to use it.

The GlucaGen Hypokit can be purchased on prescription at the chemist and contains synthetic glucagon in powder form, water to mix in a syringe. The expiry date should be checked regularly.

Glucagon injection should be given as follows:
1. Remove the orange cap from the bottle of powder.
2. Remove the guard from the needle on the syringe.
3. Inject all the water from the syringe into the rubber bung of the bottle of powder, leave the syringe in the bottle.
4. Mix the powder into the water – don’t shake too vigorously – leaving your finger holding the plunger down so the liquid doesn’t come back.
5. Draw up all the glucagon if your child is over 5years of age. Draw up only half if your child is under 5 years of age.
6. Inject into the thigh.

Your child will usually wake up after 10 to 15 minutes and glucagon may make them vomit and have a headache. Continue to check their blood glucose level and give sips of sweet drink.

Overnight hypos (nocturnal hypoglycaemia)

Children sometimes wake with hypos at night, but may sleep through with the hypo going undetected. Warning signs that your child may be having overnight hypos include:
• A low BGL before breakfast
• Confusion, nightmares or seizures overnight
• Altered mood, headache or confusion on waking

Overnight hypos are more likely to occur after excessive exercise, less than usual food intake or if the child is unwell.

To reduce the risk of overnight hypos, it’s recommended that:
• Your child’s BGL at midnight is between 7-10mmol/L
• Your child eats an adequate supper including low glycemic index choices such as milk, yoghurt or raisin toast
• You discuss adjusting your child’s insulin dose for exercise with your diabetes team
• You check your child’s BGL throughout the night (eg. midnight, 3am) if you suspect an overnight hypo (see above)

Hypo unawareness

An inability to detect a hypo is common in young children as a result of their stage of growth and development – they’re too young to understand. Hypo unawareness on the other hand occurs when a child who previously had the ability to recognise hypo loses this ability.

Hypo unawareness can be associated with tightly controlled BGLs or as a result of frequent overnight hypos. This can cause problems, as the child has to rely on others to detect when they’re having a hypo. If you are concerned that your child has hypo unawareness, discuss this with your diabetes team. Sometimes making target BGLs at a higher level for a short period can help return hypo awareness.