Hypoglycemia in Children and Adolescents With Type 1 Diabetes Mellitus

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Hypoglycemia in children and adolescents with type 1

diabetes mellitus
AUTHORS: Lynne L Levitsky, MD, Madhusmita Misra, MD, MPH
SECTION EDITOR: Joseph I Wolfsdorf, MD, BCh
DEPUTY EDITOR: Alison G Hoppin, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Dec 30, 2022.
INTRODUCTION
Hypoglycemia is a common complication of type 1 diabetes mellitus (T1DM) in childhood [1].

It can occur in any child in whom the dose of administered insulin exceeds the insulin
requirement. Avoiding severe and recurrent hypoglycemia is an important goal of diabetes
management because these events can lead to acute and permanent neurologic
complications. Fortunately, setting stringent targets for glycemic control generally does not
increase the risk for severe hypoglycemic events and good glycemic control may improve
cognitive development [2,3].
The symptoms, risk factors, prevention, and treatment of hypoglycemia in children and
adolescents with T1DM are discussed in this topic review. Other issues in this population are
discussed separately:
● (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children

and adolescents".)
● (See "Overview of the management of type 1 diabetes mellitus in children and

adolescents".)
● (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)
● (See "Complications and screening in children and adolescents with type 1 diabetes
mellitus".)
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/hypoglycemia-in-children-and-adolescents-with-type-1-diabetes-mellitus/print?s… 1/30
● (See "Management of exercise for children and adolescents with type 1 diabetes
mellitus".)
● (See "Management of type 1 diabetes mellitus in children during illness, procedures,

school, or travel".)
DEFINITIONS AND PATHOPHYSIOLOGY
An international consensus panel defined the following important thresholds for

categorizing hypoglycemic episodes in children with T1DM [3,4]:
● Clinical hypoglycemia alert – Blood glucose <70 mg/dL (3.9 mmol/L); this is commonly
used as a threshold for recognizing and initiating treatment for hypoglycemia.
● Clinically important or serious hypoglycemia – Blood glucose <54 mg/dL (3.0 mmol/L);
values in this range tend to be associated with defective glucose counterregulation,
impaired hypoglycemia awareness, and, sometimes, cognitive dysfunction.
● Severe hypoglycemia – An event associated with severe cognitive impairment (including

coma and seizures), requiring assistance of another person to correct, including
administration of carbohydrates or glucagon or intravenous (IV) dextrose.
Although these blood glucose thresholds are somewhat arbitrary because the clinical
correlates vary among individuals and across age groups, they provide consistent definitions
that can be applied to research and also match definitions proposed by an international
consensus panel for hypoglycemia in adults [5].
Physiologic responses to hypoglycemia include increased secretion of the counterregulatory

hormones glucagon, epinephrine, cortisol, and growth hormone. In individuals with T1DM,
the counterregulatory hormone response often becomes blunted over time, so that the
glucagon response is impaired and the epinephrine surge may be attenuated; this increases
the risk of persistent hypoglycemia. Impairment of the epinephrine response occurs in 30
percent or more of children and adolescents whose diabetes is well controlled [6]. This is
especially likely to occur in tightly controlled patients with frequent biochemical
hypoglycemia. (See "Physiologic response to hypoglycemia in healthy individuals and
patients with diabetes mellitus".)
RISK FACTORS
The risk of hypoglycemia is associated with the following:
Young age — Hypoglycemic episodes are more common and severe in younger children
because food intake, activity, and adherence to treatment schedules are less predictable in
younger compared with older children. Aiming for very tight glycemic control can further
increase the risk of hypoglycemia in this age group, although this risk can be reduced with
the use of a continuous glucose monitoring (CGM) device together with a pump that has a
predictive low glucose insulin suspend feature [7]. (See "Overview of the management of
type 1 diabetes mellitus in children and adolescents", section on 'Age-based care'.)
In a large multicenter registry, severe hypoglycemia occurred in 9.6 percent of children 2 to

<6 years of age, as compared with 5.2 percent of those 6 to <13 years and 6.3 percent of
those 13 to <18 years [8]. In a second observational study, the incidence of severe
hypoglycemia decreased with age [9]. In girls <7 years of age, 7 to 12 years of age, and ≥13
years of age, the frequency of hypoglycemia was 24, 19, and 14 episodes per 100 patient-
years, respectively. Frequent recurrences of hypoglycemia occurred in a minority of patients,
with 20 percent of patients accounting for 80 percent of episodes.
Type of insulin regimen — Insulin dosing regimens are an important predictor of the risk of
hypoglycemia. In general, intensive insulin therapy has the advantage of improved glycemic
control and probably also reduces the risk for hypoglycemia when appropriately
administered. (See "Insulin therapy for children and adolescents with type 1 diabetes
mellitus", section on 'Value of an intensive regimen'.)
● Fixed-dose regimens – These insulin regimens consist of a fixed daily injection

schedule using intermediate- and rapid- or short-acting insulins. The incidence of
hypoglycemia in children treated with a fixed-dose regimen ranges between 20 and 60
episodes per 100 patient-years [9-11]. Such regimens are unlikely to achieve optimal
glycemic control and have largely been replaced by intensive regimens in resource-
abundant areas.
A fixed-dose insulin regimen typically includes NPH (neutral protamine hagedorn), an

intermediate-acting insulin, which peaks several hours after administration.
Hypoglycemia can occur if adequate glucose is not available at the time of peak insulin
effect. As an example, if NPH is given with dinner or at bedtime, nocturnal
hypoglycemia may occur between 12 AM to 4 AM, when NPH effect peaks ( table 1
and figure 1). The risk is increased at night because sleep impairs the
counterregulatory hormone responses to hypoglycemia. Similarly, a missed morning
snack or delayed lunch may result in hypoglycemia as a consequence of the morning
NPH insulin reaching its peak without concomitant food intake. Snacks between meals
and at bedtime that contain complex carbohydrates (with fat to delay absorption)
reduce the frequency and severity of hypoglycemic episodes in children receiving fixed-
dose insulin regimens.
● Intensive regimens – In general, an insulin replacement regimen that delivers a basal

insulin dose with intermittent boluses of rapid-acting insulin to cover food intake is
associated with a lower risk of hypoglycemia than fixed-dose insulin regimens [12-21].
The risk for hypoglycemia has been examined for specific types of intensive insulin
therapies:
• Multiple daily injections (MDI) – Most regimens use a long-acting insulin analog
(insulin glargine, detemir, or degludec) to deliver insulin at a relatively consistent
basal rate without a pronounced peak effect ( table 1). Boluses of a rapid-acting
insulin such as lispro, aspart, or glulisine are given before meals and snacks or,
sometimes, immediately after the meal or snack (particularly in very young children
or when it is uncertain whether or not the child will finish the meal/snack).
Observational studies have shown that this approach reduces the incidence of
severe hypoglycemic episodes in all age groups, including children <6 years of age,
as compared with fixed insulin regimens. These data are discussed in a separate
topic review. (See "Insulin therapy for children and adolescents with type 1 diabetes
mellitus", section on 'Multiple daily injections'.)
• Insulin pump – Insulin pump therapy (also known as continuous subcutaneous

insulin infusion) is an alternate form of intensive insulin therapy. The insulin pump
provides a continuous subcutaneous infusion of rapid-acting insulin delivered at a
basal rate, with boluses administered with meals and snacks. Controlled trials of
insulin pump therapy in this age group generally suggest that it is similar to or
somewhat better than MDI in achieving glycemic control and avoiding hypoglycemic
episodes [22,23]. These data are discussed separately. (See "Insulin therapy for
children and adolescents with type 1 diabetes mellitus", section on 'Insulin pump'.)
When using either MDI or insulin pump therapy, administration of boluses of rapid-acting or
short-acting insulin before the glucose-lowering effect of each dose has completely
dissipated is referred to as "stacking" and may precipitate hypoglycemia. To prevent
"stacking," patients should be counseled to wait at least three hours before administering
another dose of rapid-acting insulin to correct hyperglycemia.
● Glucose sensors and sensor-augmented pumps – Devices that may help to reduce
rates of hypoglycemia include:
• CGM device
• Various types of sensor-augmented insulin pumps (open-loop systems), with low

glucose suspension (suspend on low) or predictive low glucose management
(suspend before low)
Hybrid closed-loop insulin pump systems (sometimes called "artificial pancreases")

These
• devices are described in more detail in a separate topic, including their
performances for reducing hypoglycemia in children. (See "Insulin therapy for children
and adolescents with type 1 diabetes mellitus", section on 'Automated insulin delivery
(hybrid closed-loop insulin pumps)' and "Insulin therapy for children and adolescents
with type 1 diabetes mellitus", section on 'Insulin pumps with glucose sensors'.)
Exercise — Exercise is a well-established cause of hypoglycemia because exercise enhances

insulin sensitivity, increases utilization of glucose, and increases insulin absorption from the
injection site due to increased blood flow. The hypoglycemic effects of exercise can be
delayed several hours and can vary among individuals and with the intensity and duration of
exercise.
Recommendations to avoid hypoglycemia during and after exercise include:
● Monitoring blood glucose before, during, and after vigorous activity. If this is a new
activity, monitoring should be done up to 12 hours after physical activity because of
possible delayed effects.
● Consuming a snack before and/or during the time of increased activity.
● Reducing the last insulin dose before activity.
● Reducing the basal rate of the insulin pump (by setting a "temporary" basal rate) for the
duration of exercise and for a variable period thereafter.
Automated systems to adjust insulin infusions may also reduce the risk of hypoglycemia
during exercise. Preliminary studies suggest benefits from use of a predictive low glucose
suspend system or a closed-loop control system [24-26]. (See "Insulin therapy for children
and adolescents with type 1 diabetes mellitus", section on 'Insulin pumps with glucose
sensors'.)
Exercise can cause paradoxical hyperglycemia under certain conditions, including high-
intensity activity or competition, because of release of counterregulatory hormones from
stress associated with the activity. Glycemic management during exercise is discussed in
detail in a separate topic review. (See "Management of exercise for children and adolescents
with type 1 diabetes mellitus".)
Alcohol ingestion — Alcohol ingestion is a common cause of hypoglycemic episodes in

adolescents and young adults because it suppresses gluconeogenesis and glycogenolysis
and acutely increases insulin sensitivity [1]. The combination of exercise with alcohol
ingestion further increases the risk for severe hypoglycemia.
Other risk factors
● Acute illness – During acute illnesses associated with nausea, vomiting, and anorexia,
hypoglycemia may occur because of poor oral intake if the doses of insulin with meal-
associated peaks are not appropriately adjusted. Hyperglycemia can also occur during
acute illnesses because of peripheral insulin resistance. Frequent blood glucose
monitoring is mandatory for insulin dose adjustment based upon the blood glucose
measurements. In many cases, the insulin dose may need to be reduced, but it should
only rarely be omitted entirely because hyperglycemia and diabetic ketoacidosis can
develop if basal insulin is not given. (See "Management of type 1 diabetes mellitus in
children during illness, procedures, school, or travel", section on 'Sick-day
management'.)
● Inconsistent carbohydrate intake – Variations in the timing and carbohydrate content of

food intake result in erratic glycemic effects and an increased risk of hypoglycemia.
Children who are on a fixed insulin regimen are particularly vulnerable if the schedule
and carbohydrate content of meals are not consistent, because insulin doses will not
match glycemic needs. (See "Nutritional considerations in type 1 diabetes mellitus".)
● Psychological and socioeconomic factors – Increased risk of hypoglycemia is associated

with lower socioeconomic status [9] and psychiatric disorders. (See "Complications and
screening in children and adolescents with type 1 diabetes mellitus", section on
'Psychiatric disorders'.)
● Coexisting autoimmune disorders – Celiac disease, Addison's disease, and autoimmune

thyroiditis are associated with T1DM and may increase the risk of hypoglycemia. These
disorders should be excluded in children with recurrent unexplained hypoglycemia.
(See "Associated autoimmune diseases in children and adolescents with type 1 diabetes
mellitus".)
PREVENTION AND ANTICIPATORY GUIDANCE
Targets for glycemic control — A target for hemoglobin A1c (A1C) of <7 percent (53
mmol/mol) is recommended for most children and adolescents who have access to
comprehensive diabetes care, but a more or less stringent target may be appropriate for an
individual patient [1,27]. These stringent A1C targets improve glycemic control without
significantly increasing the risk for severe hypoglycemia. Considerations for setting an A1C
target in individual patients are discussed separately. (See "Insulin therapy for children and
adolescents with type 1 diabetes mellitus", section on 'Target for hemoglobin A1c'.)
Fear of hypoglycemia — Fear of hypoglycemia on the part of the child, caregiver, or

provider can result in poor glycemic control. Some children and parents who are concerned
about hypoglycemia may keep blood glucose values above recommended targets in an
effort to avoid hypoglycemic episodes [28-31]. Counseling about this issue and careful
attention to accurate insulin dose calculations should be an important part of diabetes
management [32].
Neurologic sequelae
● Acute effects of hypoglycemia – Hypoglycemia clearly has short-term effects on

cognitive function. Even mild hypoglycemia can affect critical activities, such as driving
or performance in standardized school examinations, and reduce mental efficiency,
including attention, memory, and performance on mathematical tasks [33-36].
Severe hypoglycemia is associated with neurologic impairment, which occasionally

includes acute and transient cortical blindness [37,38]. Stroke-like hemiparesis can
occur and persist for up to 24 hours after a severe episode. These functional changes
are accompanied by altered findings on the electroencephalogram and increases in
regional cerebral blood flow [39]. Prolonged severe hypoglycemia is responsible for 5 to
10 percent of deaths in patients with T1DM [40].
● Chronic effects of hypoglycemia – Concerns have been raised that severe or repeated
episodes of hypoglycemia may have deleterious effects on brain development and
learning, particularly in young children [41-44]. Therefore, avoidance of these episodes
is an important goal of diabetes management, especially in young children. Fortunately,
studies of children and adults using modern methods of diabetes management provide
some reassurance that moderate episodes of hypoglycemia probably are not
associated with long-term cognitive sequelae [40,45-47]. As an example, in a
population-based study of children with T1DM in Denmark, there were no differences in
standardized tests for reading and mathematics between children with and those
without T1DM [47]. In addition, children with onset of T1DM before six years of age or
those with diabetes duration of more than four years did not have significantly
different test scores compared with children without T1DM. Sixty-four percent of the
children used an insulin pump, and those with tight glucose control had better test
scores than those with poor control. Similarly, among adults and adolescents enrolled
in the Diabetes Control and Complications Trial (DCCT), neither tight glucose control
(intensive therapy) nor recurrent severe hypoglycemia were associated with cognitive
deficits after an average of 6.5 years of follow-up [48]. Long-term follow-up of the DCCT
cohort after 18 years of therapy still revealed no association between cognitive function
and frequency of episodes of hypoglycemia [49]. These findings contrast with earlier
studies in which earlier onset of T1DM was associated with an increased risk for mild
neuropsychological dysfunction [50-55].
Although early onset of T1DM may be associated with an increased risk for
neuropsychological dysfunction and structural changes in the brain, it is not clear that
these effects are mediated by chronic or acute severe episodes of hypoglycemia.

Indeed, some studies suggest that chronic hyperglycemia may be responsible for
cognitive dysfunction [43,56-58] and children with a history of diabetic ketoacidosis
have lower rates of accurate memory on structured tasks than those without a history
of diabetic ketoacidosis [59,60]. These observations led to the current clinical approach
to glycemic management of T1DM, which recommends more stringent glycemic
targets, provided that episodes of severe hypoglycemia can be avoided [3,27,57]. (See
'Targets for glycemic control' above.)
Hypoglycemia unawareness — "Hypoglycemia unawareness" is a condition characterized

by a lack of warning symptoms of hypoglycemia because of blunting of the sympathetic
neural activation and epinephrine response (see 'Definitions and pathophysiology' above).
This is more commonly seen in children with long duration of diabetes and increases the risk
of severe and/or recurrent hypoglycemia. Any episode of hypoglycemia can lower the
glucose threshold at which adrenergic discharge and symptoms occur, increasing the risk for
subsequent severe hypoglycemia. Prevention of hypoglycemia for a few weeks can restore
hypoglycemia awareness.
Preparation for hypoglycemic episodes — Key precautions for all patients with T1DM are:
● Oral glucose – Always have ready access to a concentrated and rapidly absorbed
simple carbohydrate food source, such as sweetened fruit juice, glucose tablets, or cake
frosting. (See 'Mild and moderate hypoglycemia' below.)
● Glucagon – Have a glucagon kit at home, at school/daycare, and in the car during long
journeys. Prescriptions should be refilled before the date of expiration. (See 'Glucagon'
below.)
● Medical identification – Wear an identification band to ensure appropriate

intervention by emergency personnel should such a situation arise. MedicAlert is a
commonly used and excellent system.
SYMPTOMS AND SIGNS
Clinicians should inquire about symptoms of hypoglycemia during the routine care of a child
with T1DM ( table 2). Identification of nocturnal hypoglycemia is particularly important,
given reported incidences on any given night of 30 percent or more in children on insulin
pump or multiple daily injections (MDI) and higher rates in young children or those using
fixed-dose insulin regimens [61-63]. Symptoms can be subtle and include nightmares,
restless sleep, and, upon awakening, headache, confusion, or behavior changes. Decreased
release of counterregulatory hormones during sleep and/or delayed hypoglycemic response

to afternoon exercise may contribute to the risk for nocturnal hypoglycemia [64].
Nocturnal hypoglycemia is readily identified by continuous glucose monitoring (CGM)

devices, and the frequency of episodes can be decreased in children using such devices,
especially when linked to pumps with a suspend infusion function or partial closed loop.
Symptoms of hypoglycemia include:
● Adrenergic symptoms – Tremor, pallor, rapid heart rate, palpitations, and diaphoresis.
These are caused by sympathetic neural activation and epinephrine release [65].
However, episodes of hypoglycemia can lower the threshold at which these symptoms
occur, leading to "hypoglycemia unawareness" and increasing the risk for subsequent
severe hypoglycemia. (See 'Hypoglycemia unawareness' above.)
● Neuroglycopenic symptoms – Fatigue, lethargy, headaches, behavior changes,

drowsiness, unconsciousness, seizures, or coma. These symptoms result from direct
effects of hypoglycemia on the central nervous system. The severity of neuroglycopenic
symptoms increases with the severity of hypoglycemia and resultant central nervous
system glucose deprivation.
● Behavioral symptoms – Behavioral symptoms include irritability, agitation, erratic

behavior, unusual quietness, or tantrums and are most common in younger children.
These behavioral symptoms are probably a consequence of adrenergic and
neuroglycopenic responses [1].
MANAGEMENT
Hypoglycemia may be symptomatic or can be detected by a low blood glucose concentration

in the absence of symptoms. If a patient is symptomatic, measure blood glucose to confirm
the suspected hypoglycemia. Families of children monitoring glycemia with continuous
glucose monitoring (CGM) devices need to know that these devices measure the levels of
glucose in interstitial fluid. Circulating blood glucose levels equilibrate with the levels in
interstitial fluid with a lag time of 15 minutes or more. Thus, if the child has a rapid drop in
circulating blood glucose concentration, they may become symptomatic before
hypoglycemia is detected by the CGM device. If confirmation is not possible, treat
presumptively for hypoglycemia.
Classification of severity — The severity of hypoglycemia is classified by symptoms and the

response needed for successful treatment [1,40]. Although these symptom patterns are
common, children and their parents show poor ability to detect either high or low blood
glucose levels based on symptoms alone. Therefore, regular and confirmatory blood glucose
monitoring or CGM is important. (See 'Management' above and "Insulin therapy for children
and adolescents with type 1 diabetes mellitus", section on 'Blood glucose monitoring'.)
● Mild symptoms – Symptoms of mild hypoglycemia include adrenergic and mild

neuroglycopenic manifestations:
• Older children can generally recognize symptoms (headache, tremor, palpitations,

diaphoresis) and adequately treat themselves with oral intake of a rapidly absorbed
carbohydrate.
• For infants and very young children, symptoms of hypoglycemia include poor
feeding, lethargy, jitteriness, and hypotonia; these symptoms may appear over a
range of blood glucose concentrations. Young children are unable to communicate
symptoms to caregivers and may not have the same adrenergic signs as older
children. Thus, caregivers need to be trained to recognize and treat nonspecific
symptoms associated with hypoglycemia in this age group. (See 'Definitions and
pathophysiology' above.)
● Moderate symptoms – Moderate symptoms consist of sufficient neurologic

impairment such that a second person is needed to administer oral therapy.
● Severe symptoms – Severe symptoms of hypoglycemia include neurologic impairment

that precludes oral therapy, thus requiring intervention with intranasal, subcutaneous,
or intramuscular glucagon or intravenous (IV) dextrose. Symptoms may progress to
loss of consciousness, seizures, or coma.
Mild and moderate hypoglycemia — Patients with mild and moderate hypoglycemia (blood
glucose <70 mg/dL [3.9 mmol/L] and/or adrenergic and neuroglycopenic symptoms
described above) should be treated orally with a concentrated and rapidly absorbed simple
carbohydrate food source (10 to 15 g glucose). Options include:
● Glucose tablets – 5 g per tablet

● Glucose gel – 15 g per tube
● Fruit juice – 12 g carbohydrate per 4 oz (120 mL)
● Regular soda (not diet) – 12 g carbohydrate per 4 oz (120 mL)
● Honey – 17 g carbohydrate per 1 tablespoon (15 mL)
● Table sugar (granulated sugar) – 12.5 g sucrose per 1 tablespoon
● Skittles – 10 g carbohydrate (sucrose) per 10 candies
Glucose and sucrose (which is rapidly broken down to glucose and fructose) are more
effective than fructose alone in treating hypoglycemia [66]. These simple carbohydrates
rapidly raise the blood glucose concentration. A weight-based dose (0.3 to 0.6 g/kg) may also
be used, depending on the blood glucose level; one study reported that this was a more
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effective strategy to treat symptomatic hypoglycemia in children and adults compared with
non-weight-based dosing of glucose [67].
In children who use an insulin pump to deliver insulin and/or use a CGM device, this
treatment is usually sufficient. By contrast, in children receiving a fixed dose of insulin, it may
be necessary to follow this treatment with a snack that contains a carbohydrate, protein, and
fat in order to sustain blood glucose levels, such as a peanut butter sandwich or a bagel with
cream cheese or other fat and protein. Blood glucose should be checked again in 15 to 20
minutes to confirm that glucose values have normalized and to determine whether further
intervention is necessary. The patient may need to eat additional carbohydrates until blood
glucose concentrations are sustained above 100 mg/dL (5.6 mmol/L). Children managed with
an insulin pump or a hybrid closed-loop system rarely require an extra snack; indeed,
ingesting more carbohydrate than necessary to treat the hypoglycemia often leads to
rebound hyperglycemia.
In patients with poor oral intake during gastroenteritis or other illnesses, minidose glucagon
has been used effectively to prevent impending hypoglycemia or to treat mild hypoglycemia
at home.
Dosing is as follows, using a standard U100 insulin syringe:
● Children ≤2 years of age – 2 "units" (20 micrograms) of glucagon given subcutaneously

● Children 2 years and older – 1 "unit" of glucagon (10 micrograms)/year of age up to 15
"units" (150 micrograms)
A second dose (at double the initial dose) is given if blood glucose does not increase in 30
minutes [68,69].
Severe hypoglycemia — Patients with severe neurologic symptoms who are unable to take
oral therapy require intervention with glucagon and/or IV dextrose.
Glucagon — Patients with significant neurologic impairment and/or who are unable to take
oral glucose require urgent treatment with glucagon. Every person with T1DM should have a
glucagon kit readily available at all times. (See 'Preparation for hypoglycemic episodes'
above.)
Glucagon comes in several forms:
● Standard (lyophilized) glucagon – Glucagon may be administered subcutaneously or

intramuscularly at the following doses:
• ≤20 kg body weight – 0.5 mg (or 0.02 to 0.03 mg/kg)

• >20 kg body weight – 1 mg
The standard formulation of glucagon is unstable in solution; it is only available as a

lyophilized powder that requires reconstitution with a diluent immediately before use.
These doses of glucagon are usually sufficient to increase blood glucose within a few
minutes. The glucagon dose must be followed by oral intake of concentrated
carbohydrates immediately upon awakening from the confused state. This is because
both severe hypoglycemia and glucagon may cause nausea and vomiting within 45
minutes to an hour.
● Intranasal glucagon – Dosing for intranasal glucagon is:
• 3 mg intranasally initially (for ages ≥4 years)

• Administer an additional 3 mg dose (using a new device) if there has been no
glycemic response after 15 minutes
Intranasal glucagon is a unique powder formulation that is delivered through a device

designed for one-time use.
The use of intranasal glucagon in children and adolescents is supported by results from
a randomized trial and an observational study under "real-world" conditions [70,71].
The time course of the glycemic response is similar to that for intramuscularly
administered glucagon. Data on intranasal glucagon in adults are discussed separately.
(See "Hypoglycemia in adults with diabetes mellitus", section on 'Without IV access'.)
● Dasiglucagon – Dasiglucagon is a soluble glucagon analog that is available in a fixed-

dose autoinjector, with dosing:
• 0.6 mg (for ages ≥6 years), given subcutaneously via autoinjector
Because dasiglucagon does not require reconstitution, it should be easier to administer

in the stressful circumstances associated with the emergency treatment of severe
hypoglycemia (seizure or loss of consciousness). Dasiglucagon is approved in the
United States for individuals six years and older; the safety profile of this fixed dose in
children and adolescents is similar to that of glucagon [72].
● Stable liquid glucagon – A stable premixed liquid form of glucagon is available in the
following doses:
• 2 to 12 years – 0.5 mg
• ≥12 years – 1 mg
This stable liquid form is available as an autoinjector or prefilled syringe (Gvoke), which
is approved in the United States for individuals two years and older [73]. It does not
require refrigeration, and the medication is administered subcutaneously.
Intravenous dextrose — For patients with severe hypoglycemia, IV dextrose should be

given if IV access and appropriately trained medical personnel are available.
Dosing is 0.25 g/kg (maximum single dose 25 g). This is supplied by:
● 2.5 mL/kg of 10% dextrose solution or

● 1 mL/kg of 25% dextrose solution
An IV infusion sufficient to maintain glucose can be started if the child is still unable to take
orally. An infusion of 10% glucose at a maintenance rate may be required and can be titrated
up or down based upon the blood glucose, which should be checked every 30 minutes
initially. Electrolytes should be included in the IV fluids if the infusion is prolonged (eg, one
hour or more).
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Diabetes mellitus in
children" and "Society guideline links: Hypoglycemia in infants and children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Type 1 diabetes (The Basics)" and "Patient
education: My child has diabetes: How will we manage? (The Basics)" and "Patient
education: Managing blood sugar in children with diabetes (The Basics)" and "Patient
education: Carb counting for children with diabetes (The Basics)" and "Patient
education: Managing diabetes in school (The Basics)" and "Patient education: Giving
your child insulin (The Basics)" and "Patient education: Checking your child's blood
sugar level (The Basics)" and "Patient education: Should I switch to an insulin pump?
(The Basics)")
● Beyond the basics topics (see "Patient education: Type 1 diabetes: Overview (Beyond
the Basics)")
SUMMARY AND RECOMMENDATIONS
● Risk factors – Risk factors for hypoglycemia in children with type 1 diabetes mellitus
(T1DM) include younger age, a split-mixed insulin regimen with a fixed daily insulin
schedule, increased vigorous activity (exercise), alcohol ingestion, acute illnesses, and
depression. (See 'Risk factors' above.)
● Blood glucose thresholds for categorizing hypoglycemia – In children with T1DM, an

alert value for hypoglycemia is defined as blood glucose <70 mg/dL (3.9 mmol/L).
Clinically important hypoglycemia is defined as blood glucose <54 mg/dL (3.0 mmol/L).
(See 'Definitions and pathophysiology' above.)
● Prevention and anticipatory guidance – Counseling to children and families includes:
• Good glycemic control using modern methods for insulin administration, insulin
analogs, and frequent blood glucose monitoring (including continuous glucose
monitoring [CGM]) does not increase the risk for hypoglycemia or long-term
cognitive sequelae. However, severe or repeated episodes of hypoglycemia may
have deleterious effects on brain development and learning, particularly in young
children, and should be avoided. (See 'Neurologic sequelae' above.)
• "Hypoglycemia unawareness" is a condition characterized by a lack of warning

symptoms of hypoglycemia because of blunting of the sympathetic neural and
epinephrine response to hypoglycemia. This is more commonly seen in children with
long duration of diabetes and recurrent episodes of hypoglycemia and increases the
risk of severe hypoglycemia. (See 'Hypoglycemia unawareness' above.)
• Important precautions for all individuals with T1DM include having ready access to a
concentrated and rapidly absorbed simple carbohydrate food source, having a
glucagon kit at home and wherever they spend time, and wearing a medical alert
that identifies them as having T1DM. (See 'Preparation for hypoglycemic episodes'
above.)
● Clinical classification of severity – Because the clinical response to hypoglycemia

varies, hypoglycemia is further classified by severity of symptoms and the response
needed for successful treatment of the patient. (See 'Classification of severity' above.)
• Mild symptoms of hypoglycemia include tremor, palpitations, diaphoresis,

headaches, and behavior changes. There is little or no functional impairment, and
older children can treat themselves with oral intake of a rapidly absorbed
carbohydrate.
• Moderate neurologic symptoms consist of sufficient neurologic impairment such

that a second person has to administer oral therapy.
• Severe neurologic symptoms consist of unresponsiveness, seizures, or coma, such

that the patient is unable to take oral therapy and requires subcutaneous
administration of glucagon or administration of intravenous (IV) dextrose.
● Management of hypoglycemia
• Patients who can take oral therapy – Patients with mild and moderate neurologic
symptoms should be treated promptly with a concentrated and rapidly absorbed
simple carbohydrate food source, such as fruit juice, glucose tablets, Skittles candy,
or cake frosting. In children who use an insulin pump and/or a CGM device, this
treatment is usually sufficient. However, children on a fixed-dose insulin regimen
may require an additional longer-lasting snack containing carbohydrate, fat, and
protein in order to sustain a normal blood glucose level. Blood glucose should be
checked again in 15 to 20 minutes to confirm that glucose values have normalized
and to determine whether further intervention is necessary. (See 'Mild and
moderate hypoglycemia' above.)
• Patients who cannot take oral therapy – Patients with severe neurologic
impairment require prompt treatment with glucagon or IV dextrose (see 'Severe
hypoglycemia' above):
- For standard (lyophilized) glucagon, give 0.02 to 0.03 mg/kg (maximum dose 1
mg). Different doses are used for other formulations of glucagon (stable liquid
form [fixed-dose], intranasal, or a soluble liquid analog [dasiglucagon]). (See
'Glucagon' above.)
- For IV dextrose, give 2.5 mL/kg of 10% dextrose solution or 1 mL/kg of 25%
dextrose solution (both are equivalent to 0.25 g/kg; maximum single dose 25 g).
(See 'Intravenous dextrose' above.)
Use of UpToDate is subject to the Terms of Use.
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both hypo- and hyperglycemia in school-aged children with type 1 diabetes: a field
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37. Mukamel M, Weitz R, Nissenkorn I, et al. Acute cortical blindness associated with
hypoglycemia. J Pediatr 1981; 98:583.
38. Garty BZ, Dinari G, Nitzan M. Transient acute cortical blindness associated with
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39. Ryan CM, Becker DJ. Hypoglycemia in children with type 1 diabetes mellitus. Risk factors,
cognitive function, and management. Endocrinol Metab Clin North Am 1999; 28:883.
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months. Diabetes Care 2003; 26:1100.
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cognitive performance in children with type 1 diabetes: a meta-analysis. J Child Neurol
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diabetes and its treatment on cognitive function. N Engl J Med 2007; 356:1842.
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53. Hershey T, Perantie DC, Warren SL, et al. Frequency and timing of severe hypoglycemia
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54. Wootton-Gorges SL, Glaser NS. Imaging of the brain in children with type I diabetes
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58. Barnea-Goraly N, Raman M, Mazaika P, et al. Alterations in white matter structure in
young children with type 1 diabetes. Diabetes Care 2014; 37:332.
59. Ghetti S, Lee JK, Sims CE, et al. Diabetic ketoacidosis and memory dysfunction in children
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60. Shehata G, Eltayeb A. Cognitive function and event-related potentials in children with
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62. Beregszàszi M, Tubiana-Rufi N, Benali K, et al. Nocturnal hypoglycemia in children and
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64. Jones TW, Porter P, Sherwin RS, et al. Decreased epinephrine responses to hypoglycemia
during sleep. N Engl J Med 1998; 338:1657.
65. DeRosa MA, Cryer PE. Hypoglycemia and the sympathoadrenal system: neurogenic
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activation. Am J Physiol Endocrinol Metab 2004; 287:E32.
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and fructose in treating hypoglycemia in children with type 1 diabetes. Pediatr Diabetes
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67. McTavish L, Corley B, Weatherall M, et al. Weight-based carbohydrate treatment of
hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a
randomized crossover clinical trial. Diabet Med 2018; 35:339.
68. Haymond MW, Schreiner B. Mini-dose glucagon rescue for hypoglycemia in children
with type 1 diabetes. Diabetes Care 2001; 24:643.
69. Hartley M, Thomsett MJ, Cotterill AM. Mini-dose glucagon rescue for mild hypoglycaemia
in children with type 1 diabetes: the Brisbane experience. J Paediatr Child Health 2006;
42:108.
70. Sherr JL, Ruedy KJ, Foster NC, et al. Glucagon Nasal Powder: A Promising Alternative to
Intramuscular Glucagon in Youth With Type 1 Diabetes. Diabetes Care 2016; 39:555.
71. Deeb LC, Dulude H, Guzman CB, et al. A phase 3 multicenter, open-label, prospective
study designed to evaluate the effectiveness and ease of use of nasal glucagon in the
treatment of moderate and severe hypoglycemia in children and adolescents with type 1
diabetes in the home or school setting. Pediatr Diabetes 2018; 19:1007.
72. Battelino T, Tehranchi R, Bailey T, et al. Dasiglucagon, a next-generation ready-to-use
glucagon analog, for treatment of severe hypoglycemia in children and adolescents with
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22:734.
73. Manufacturer's prescibing information for GVOKE, 8/2021. Available at: https://www-acc
essdata-fda-gov.bibliotecavirtual.udla.edu.ec/drugsatfda_docs/label/2021/212097s007lb
l.pdf (Accessed on August 23, 2021).
Topic 97229 Version 22.0
GRAPHICS
Available insulins [1]
Onset Peak Duration

Type Comments
(hours) (hours) (hours)
Ultra-rapid-acting
Faster aspart 0.1 to 0.2 1 to 3 3 to 5 Duration of action may be

shorter.
Insulin lispro-aabc
Rapid-acting
Lispro*/aspart*/glulisine 0.15 to 0.35 1 to 3 3 to 5
Short-acting
Regular 0.5 to 1 2 to 4 5 to 8 Longer duration of action

if larger dose.
Intermediate-acting
NPH 2 to 4 4 to 12 12 to 24 Peak and duration quite

variable.
NPL Approximately 6 15 Activity profile similar to

2 NPH; can be mixed with
insulin lispro. Not
available in the United
States.
Basal long-acting
Glargine* 2 to 4 8 to 12 (not 22 to 24 Half-life is shorter in some

pronounced) patients, requiring
division of the daily dose
into 2 injections per day.
Cannot be mixed with

other insulins, because
this alters
pharmacokinetics.
Detemir 1 to 2 4 to 7 (not 20 to 24 Duration of action is dose

pronounced) dependent. At higher
doses (≥0.8 units/kg),
mean duration of action i
longer and less variable
(22 to 23 hours). At lower
doses, mean duration of
action is shorter and
twice-daily injections are
often needed.
Cannot be mixed with

this alters
pharmacokinetics.
Glargine U300 2 to 6 None 30 to 36 Cannot be mixed with

this alters
pharmacokinetics.
Degludec 0.5 to 1.5 None >42 Less day-to-day variation

in glucose-lowering effect
at steady state (after 2 to
3 days' use) relative to
glargine U100 and
detemir.
Can be mixed with insulin

aspart; coformulation
with aspart available in
some countries.
The numbers indicated above are approximations and are influenced by many factors including (but
not limited to) presence and type of antibodies to the specific insulin, site of injection, and mass action
effect. Premixed insulins are not generally recommended but are sometimes useful to reduce the
number of injections in selected patients; mixes consist of NPH and regular (70:30 mix) or NPH and
Lispro (75:25 mix), as well as other concentrations. Other new insulins are presently in clinical trials.
No inhaled insulin preparation is currently available, but both orally absorbed and inhaled insulin
preparations are being developed.
NPH: neutral protamine hagedorn; NPL: neutral protamine lispro.
* Certain biosimilar insulins for lispro, aspart, and glargine are approved for children in some
countries, including the United States, Canada, and Europe. The US Food and Drug Administration
uses the term "similar" rather than "biosimilar" for technical reasons [2] .
References:
1. Cengiz E, Danne T, Ahmad T, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Insulin treatment in children and
adolescents with diabetes. Pediatr Diabetes 2022; 23:1277.
2. In brief: Another insulin lispro (Admelog) for diabetes. Med Lett Drugs Ther 2018; 60:e109.
Graphic 61880 Version 12.0
Effect of twice-daily insulin regimen
Twice-daily administration of regular (solid lines) and intermediate-acting lente or NPH (dashed lines)
insulins before breakfast and the evening meal provides peaks of insulin after the injections as well as
a relatively constant baseline level of insulin throughout the day after injections of the intermediate-
acting insulins.
NPH: neutral protamine hagedorn.
Routine monitoring of children and adolescents with type 1 diabetes for

complications
Initiate Repeat at
Evaluation Purpose Abnormal result
screening least
Hypoglycemia Ask about After Every 3 Frequent episodes of

assessment episodes of diagnosis of months. hypoglycemia (blood
hypoglycemia diabetes. glucose level <70
and associated mg/dL), especially e
symptoms, and with hypoglycemia
review records unawareness.
of blood glucose
monitoring. C
Evaluate for c
hypoglycemia g
unawareness.
a
d
Psychosocial Screen for At diagnosis Every 3 Clinical symptoms of

assessment depression, of diabetes. months. depression, eating
family conflict, disorder, or
Assess for
risk-taking psychosocial
psychosocial
behaviors, or dysfunction.
and diabetes- s
other
related stress c
psychosocial
starting at 7
dysfunction.
to 8 years of c
Offer time alone age.
with clinician, c
Screen for
starting at age a
eating
12 years when
disorders
developmentally
starting at 10 c
appropriate.
to 12 years of g
In older children age. c
and
adolescents, a
screen for
eating
disorders, and
provide
anticipatory
counseling and
screen for
smoking and
use of e-
cigarettes.
Smoking Ask about use At initial Every 3 History of smoking or

or diabetes visit. months. vaping. s
experimentation v
with tobacco
products o
including vaping e
(e-cigarettes). c
BP Screen for At diagnosis Every 3 Elevated BP

hypertension. of diabetes. months. (prehypertension) [1,2] :
<13 years – BP a
≥90 to 95 th w
percentile a
≥13 years – SBP I
120 to 129
mmHg with DBP
<80 mmHg
(measured on 3
occasions)
Hypertension [1] : I
<13 years – BP
≥95 th percentile
for age, sex, and
height
≥13 years – BP
≥130/80 mmHg
(measured on 3 A
occasions)
Foot examination Screen for Age ≥10 Annually. Inspection, palpation O

with testing for polyneuropathy. years (or of dorsalis pedis and c
vibration (tuning onset of posterior tibial pulses, g
fork) and pressure puberty, if assessment of
(10 g earlier) and if vibration,
monofilament) the youth has proprioception and 10 a
had diabetes g monofilament (
for ≥5 years. sensation. t
Urine Screen for Age ≥10 Annually. >30 mg albumin/g A

albumin:creatinine nephropathy. years (or creatinine (in at least A
ratio (spot onset of 2 of 3 urine samples
specimen) puberty, if over a 6-month
earlier) and if interval, following
the youth has efforts to improve
had diabetes glycemic control and
for ≥5 years. normalize BP) ¶ .
A1C Glycemic At diagnosis Every 3 Goal A1C <7% for O

control. of diabetes. months. most children and c
adolescents Δ [2] . g
a
(
t
Lipid profile Screen for At diagnosis If initial LDL LDL ≥100 mg/dL.
dyslipidemia. of diabetes, ≤100, initiate
once initial serial testing at o
glycemic age 9 to 11 c
control is years and a
achieved and repeat every 3 d
age ≥2 years if normal. (
years ◊ . Repeat a
annually if LDL (
If sample was
is abnormal or c
nonfasting
if glycemic
(random) and
control is poor.
results
abnormal, LDL ≥130 to 159
confirm with mg/dL.
a fasting lipid (
panel. c
i
f
(
s
a
c
LDL ≥160 mg/dL.
(
c
y
s
a
c
TSH Screen for At diagnosis Every 1 to 2 Elevated TSH. T

hypothyroidism of diabetes, years, or if
caused by after patient symptoms of
autoimmune is clinically hypothyroidism
thyroiditis. stable or develop, or if
soon after anti-thyroid
glycemic antibodies are
control is present.
established ◊ .
tTG, IgA Screen for celiac At diagnosis Repeat within 2 Positive results of
disease. of diabetes. years of antibody test. w
diagnosis, then e
after 5 years,
or if g
gastrointestinal
symptoms
develop, and
more
frequently if a
first-degree
relative has
celiac disease § .
Dilated eye Screen for Age ≥11 Repeat every 2 Background, O

examination retinopathy. years (or years. May be preproliferative, or g
onset of done less proliferative
puberty, if frequently retinopathy.
earlier), and based on risk
the child has factor t
had diabetes assessment a
for 3 to 5 (including A1C
years. ≤8%) and
advice of an
eye care
professional.
This table reflects recommendations for routine monitoring of children and adolescents with type 1
diabetes, as outlined by the ADA [1] .
BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; ACE: angiotensin-
converting enzyme; ARB: angiotensin receptor blocker; A1C: hemoglobin A1c (glycated hemoglobin);
LDL: low-density lipoprotein; CVD: cardiovascular disease; TSH: thyroid-stimulating hormone; tTG:
tissue transglutaminase; IgA: immunoglobulin A; ADA: American Diabetes Association; TPO: thyroid
peroxidase.
* ACE inhibitors (eg, lisinopril or enalapril) and ARBs have teratogenic potential, so appropriate
reproductive counseling should be given to young women. Aim for BP consistently <90 th percentile
for age, sex, and height.
¶ Transient albuminuria is common in children. Abnormal results should be confirmed on at least 2

occasions, ruling out orthostatic albuminuria, or with a 24-hour urine collection.
Δ More or less stringent goals may be appropriate for individual patients, depending on their
personal history of severe hyperglycemia, severe hypoglycemia, and hypoglycemia unawareness.
◊ Glycemic control should be established before performing the lipid profile or thyroid screening. The
ADA suggests that antibodies to TPO and thyroglobulin should be measured at diagnosis.
§ More frequent screening for celiac disease may be appropriate for children who have a first-degree
relative with celiac disease. Measurement of tTg is sufficient if IgA is normal. Antibody testing is only
valid if performed on a gluten-containing diet.
References:
1. American Diabetes Association Professional Practice Committee, Draznin B, Aroda VR, et al. 14. Children and
Adolescents: Standards of Medical Care in Diabetes-2022. Diabetes Care 2022; 45:S208.
2. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood
Pressure in Children and Adolescents. Pediatrics 2017; 140.
3. Bjornstad P, Dart A, Donaghue KC, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Microvascular and
macrovascular complications in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1432.

Hypoglycemia in Children and Adolescents With Type 1 Diabetes Mellitus

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23/2/24, 13:44 Hypoglycemia in children and adolescents with type 1 diabetes mellitus - UpToDate

Official reprint from UpToDate®

Hypoglycemia in children and adolescents with type 1

Literature review current through: Jan 2024.

Hypoglycemia is a common complication of type 1 diabetes mellitus (T1DM) in childhood [1].

● (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children

● (See "Overview of the management of type 1 diabetes mellitus in children and

● (See "Management of type 1 diabetes mellitus in children during illness, procedures,

DEFINITIONS AND PATHOPHYSIOLOGY

An international consensus panel defined the following important thresholds for

● Severe hypoglycemia – An event associated with severe cognitive impairment (including

Physiologic responses to hypoglycemia include increased secretion of the counterregulatory

The risk of hypoglycemia is associated with the following:

In a large multicenter registry, severe hypoglycemia occurred in 9.6 percent of children 2 to

● Fixed-dose regimens – These insulin regimens consist of a fixed daily injection

A fixed-dose insulin regimen typically includes NPH (neutral protamine hagedorn), an

● Intensive regimens – In general, an insulin replacement regimen that delivers a basal

• Insulin pump – Insulin pump therapy (also known as continuous subcutaneous

• Various types of sensor-augmented insulin pumps (open-loop systems), with low

Hybrid closed-loop insulin pump systems (sometimes called "artificial pancreases")

Exercise — Exercise is a well-established cause of hypoglycemia because exercise enhances

Recommendations to avoid hypoglycemia during and after exercise include:

● Consuming a snack before and/or during the time of increased activity.

● Reducing the last insulin dose before activity.

Alcohol ingestion — Alcohol ingestion is a common cause of hypoglycemic episodes in

Other risk factors

● Inconsistent carbohydrate intake – Variations in the timing and carbohydrate content of

● Psychological and socioeconomic factors – Increased risk of hypoglycemia is associated

● Coexisting autoimmune disorders – Celiac disease, Addison's disease, and autoimmune

PREVENTION AND ANTICIPATORY GUIDANCE

Fear of hypoglycemia — Fear of hypoglycemia on the part of the child, caregiver, or

● Acute effects of hypoglycemia – Hypoglycemia clearly has short-term effects on

Severe hypoglycemia is associated with neurologic impairment, which occasionally

these effects are mediated by chronic or acute severe episodes of hypoglycemia.

Hypoglycemia unawareness — "Hypoglycemia unawareness" is a condition characterized

● Medical identification – Wear an identification band to ensure appropriate

SYMPTOMS AND SIGNS

release of counterregulatory hormones during sleep and/or delayed hypoglycemic response

Nocturnal hypoglycemia is readily identified by continuous glucose monitoring (CGM)

Symptoms of hypoglycemia include:

● Neuroglycopenic symptoms – Fatigue, lethargy, headaches, behavior changes,

● Behavioral symptoms – Behavioral symptoms include irritability, agitation, erratic

Hypoglycemia may be symptomatic or can be detected by a low blood glucose concentration

Classification of severity — The severity of hypoglycemia is classified by symptoms and the

● Mild symptoms – Symptoms of mild hypoglycemia include adrenergic and mild

• Older children can generally recognize symptoms (headache, tremor, palpitations,

● Moderate symptoms – Moderate symptoms consist of sufficient neurologic

● Severe symptoms – Severe symptoms of hypoglycemia include neurologic impairment

● Glucose tablets – 5 g per tablet

Dosing is as follows, using a standard U100 insulin syringe:

● Children ≤2 years of age – 2 "units" (20 micrograms) of glucagon given subcutaneously

Glucagon comes in several forms:

● Standard (lyophilized) glucagon – Glucagon may be administered subcutaneously or

• ≤20 kg body weight – 0.5 mg (or 0.02 to 0.03 mg/kg)

The standard formulation of glucagon is unstable in solution; it is only available as a

● Intranasal glucagon – Dosing for intranasal glucagon is:

• 3 mg intranasally initially (for ages ≥4 years)

Intranasal glucagon is a unique powder formulation that is delivered through a device

● Dasiglucagon – Dasiglucagon is a soluble glucagon analog that is available in a fixed-

• 0.6 mg (for ages ≥6 years), given subcutaneously via autoinjector

Because dasiglucagon does not require reconstitution, it should be easier to administer

Intravenous dextrose — For patients with severe hypoglycemia, IV dextrose should be

● 2.5 mL/kg of 10% dextrose solution or

Lispro/aspart/glulisine 0.15 to 0.35 1 to 3 3 to 5