Prevention

When faced in clinic with a child who is having recurrent episodes of hypoglycaemia, a detailed history should be obtained regarding the timing of hypoglycaemia, insulin regimen, dietary intake and the relation to periods of physical activity. This will enable an assessment to be made of possible risk factors and inform how these may be avoided. If no obvious cause is found then other pathology should be sought, such as coincidental coeliac disease or the possibility of Addison's disease, although these are relatively rare causes of recurrent hypoglycaemia (see Chapter 3).

When contemplating preventive management the following aspects should be considered.

Check blood glucose - Glucose meter test and formal laboratory glucose if possible

Hypoglycaemia

Mild

Severe

CONSCIOUS i.e. gag reflex intact

UNCONSCIOUS

Oral glucose e.g. 5-15 grams of glucose or 100 mls sweet drink

Glucogel One ampoule orally

Success

No success

If no response in 15 mins give 1-2 mls/kg of 10% dextrose I.V. Repeat until there is a clinical response.

As symptoms improve or normoglycaemia is restored add oral complex carbohydrate e.g. biscuit, bread and so on. If unable to tolerate oral carbohydrate may need a glucose infusion e.g. 5-10% glucose at maintenance rate

Figure 9.3 Management of hypoglycaemia

Education

Great importance is placed on education in the management of type 1 diabetes and structured education programmes are now an essential part of any diabetes service provision. Despite this, little validation has been made of the use of structured educational programmes in children. One study from Scandinavia has shown the benefits of a focused education package (Nordfelt et al., 2003). In this study families were given both written and video information on diabetes. One group were given general information on diabetes management and the other was given material to educate about the importance and means of hypoglycaemia avoidance. Although no differences in glycated haemoglobin were found between the two groups, those who had the targeted intervention had a significantly reduced rate of severe hypoglycaemia (Nordfelt et al., 2003).

Insulin

As noted earlier, the DCCT suggested that attempts to intensify insulin regimens may increase the risk of severe hypoglycaemia. Recent introductions of analogue insulins, however, indicate that improved glycaemic control does not always lead to hypoglycaemia, although few studies have been designed specifically to examine the benefits of different insulin regimens on the risk of hypoglycaemia. One study that compared insulin lispro with soluble (short-acting) insulin as part of a basal bolus regimen, showed small but statistically significant reductions in the prevalence of hypoglycaemia over a 30 day period when insulin lispro was being used (Holcombe et al., 2002). Other studies have found benefits of insulin analogue regimens on nocturnal hypoglycaemia. One randomised cross-over study in adolescents compared insulin lispro and glargine, as part of a daily multiple injection regimen, to human soluble and isophane insulins. Nocturnal hypoglycaemia was 43% lower with the analogue regimen, although no difference was observed in self-reported symptomatic hypoglycaemia (Murphy et al., 2003). Another study in prepubertal children examined the benefits of a thrice daily insulin regimen, where the evening dose of mixed insulin was replaced by a rapid-acting insulin analogue with the evening meal and isophane insulin before bed (Ford-Adams et al., 2003). Although there was no difference in glycated haemoglobin between the two treatment arms, the prevalence of hypoglycaemia was lower in the early part of the night (22.00-04.00 hours) when the analogue was used.

Although not every patient is suited to using insulin pump therapy, clinic-based studies of CSII therapy have shown that more stable blood glucose control can be achieved without an increased risk of hypoglycaemia. In an American study describing the experience of using insulin pumps in a paediatric clinic, it was found that 50 adolescents on multiple daily injections experienced 134 episodes of severe hypoglycaemia per 100 patient-years compared to 76 episodes per 100 patient-years in the 25 adolescents who opted for pump therapy (Boland et al., 1999).

Diet

Few studies have examined the impact of dietary interventions on hypoglycaemia risk except for nocturnal hypoglycaemia. The major dietary modification has been that of the introduction of a larger proportion of starch, as a form of long-acting carbohydrate, as part of the evening snack (Ververs et al., 1993; Kaufman et al., 1995; Detlofson et al., 1999; Matyka et al., 1999a). In these studies the benefits of starch have been inconsistent. One study found a lower frequency of nocturnal hypoglycaemia, although capillary sampling was performed only intermittently during the night and some episodes of hypoglycaemia may have been undetected (Kaufman et al., 1995). Others found no beneficial effect of cornstarch on the prevention of nocturnal hypoglycaemia although blood glucose concentrations fell more slowly, but in one study this occurred at the expense of promoting hyperglycaemia (Ververs et al., 1993; Matyka et al., 1999a). Although not designed to examine the impact of diet on hypoglycaemia, a study of a low glycaemic index diet has been shown to improve glycaemic control without an increase in rate of hypoglycaemia, and appeared to have enhanced quality of life (Gilbertson et al., 2001)

Exercise

When adequate plasma insulin concentrations are available, exercise can lead to acute hypoglycaemia. However if exercise is performed at a time of relative insulin deficiency, hyperglycaemia with ketosis can occur. In addition, delayed hypoglycaemia may occur as muscle glycogen stores recover mainly overnight (Admon et al., 2005; Tsalikian et al., 2005). Although few data are currently available regarding the most appropriate management of planned periods of physical activity, a number of guidelines have been proposed. The International Society for Paediatric and Adolescent Diabetologists has published guidelines on the Internet (www.ispad.org). These recommend that careful monitoring of blood glucose is essential to match food and insulin to the intensity of exercise and that a reduction of insulin should be considered. Additional slowly absorbed carbohydrate will be necessary, especially at bedtime, if exercise has been performed in the afternoon or early evening. From the data available so far (Admon et al., 2005; Tsalikian et al., 2005), these guidelines do seem a reasonable approach to the avoidance of both exercise related hypo- and hyperglycaemia. It is important, however, to work with the child and family to provide individually-tailored recommendations that are tried and tested for the child. The management of unpredictable episodes of physical activity are likely to remain a problem until a cure for diabetes is found.

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