Management of Hypoglycemia in Pediatric Patients
Prompt recognition and treatment of hypoglycemia in pediatric patients is essential to prevent serious complications including cognitive deficits, seizures, and coma. The management approach should be tailored based on the severity of hypoglycemia and the patient's level of consciousness.
Definition and Recognition
- Hypoglycemia in pediatric patients is commonly defined as blood glucose <70 mg/dL (3.9 mmol/L), with severe hypoglycemia characterized by altered consciousness requiring assistance from another person 1
- Nocturnal hypoglycemia is common in children with diabetes, with reported incidence of 14-47%, and may be asymptomatic or present with nightmares, restless sleep, headache, or behavior changes upon waking 1
- Recognition of hypoglycemia symptoms is age-dependent, with infants and toddlers having limited ability to detect and communicate symptoms, necessitating more frequent monitoring 1
Treatment Algorithm Based on Severity
Mild Hypoglycemia (patient can self-treat)
- Administer 15g of rapidly absorbed carbohydrate (10g may be appropriate for younger children) 1
- Examples include glucose tablets or solution, which are more effective than fruit juice or glucose gel 2
- Recheck blood glucose after 15 minutes; if still <70 mg/dL, repeat treatment 1
- Follow with protein-containing snack once blood glucose normalizes 1
Moderate Hypoglycemia (requires assistance but conscious)
- Administer 20-30g of glucose orally to restore blood glucose to >80 mg/dL 1
- Common symptoms include neuroglycopenia (drowsiness, confusion, aggressiveness) and autonomic symptoms 1
- Monitor response and repeat treatment if necessary 1
Severe Hypoglycemia (unconscious or unable to swallow)
- For children >25kg or ≥6 years: administer glucagon 1mg subcutaneously, intramuscularly, or intravenously 3
- For children <25kg or <6 years: administer glucagon 0.5mg subcutaneously, intramuscularly, or intravenously 3
- If no response after 15 minutes, repeat dose while waiting for emergency assistance 3
- Once the patient regains consciousness, provide oral carbohydrates to restore liver glycogen and prevent recurrence 3
- For healthcare settings, intravenous glucose may be administered under medical supervision 1
Mini-Dose Glucagon for Impending Hypoglycemia
- For children with impending hypoglycemia during illness or poor oral intake, mini-dose glucagon can be effective 4
- Children ≤2 years: administer 20 μg (2 "units" on insulin syringe) subcutaneously 4
- Children >2 years: administer 10 μg/kg (1 "unit"/year of age) up to 150 μg maximum 4
- If blood glucose does not increase within 30 minutes, double the initial dose 4
Prevention Strategies
- Frequent blood glucose monitoring, especially before, during, and after exercise 1
- Maintain pre-exercise blood glucose levels between 90-250 mg/dL (5.0-13.9 mmol/L) 1
- For exercise-related hypoglycemia prevention:
- Reduce prandial insulin by 10-50% for meals before exercise 1
- Increase carbohydrate intake before, during, and after physical activity 1
- Consider bedtime snacks to prevent delayed nocturnal hypoglycemia 1
- For patients on insulin pumps, lower basal rates by 10-50% or suspend for 1-2 hours during exercise 1
- Consider decreasing basal rates or long-acting insulin doses by 20% after exercise 1
Special Considerations
- Hypoglycemia unawareness (defective glucose counterregulation) can develop after repeated hypoglycemic episodes, requiring more vigilant monitoring 1, 5
- For patients with hypoglycemia unawareness, a 2-3 week period of scrupulous avoidance of hypoglycemia is recommended 5
- Severe hypoglycemia in young children may be associated with cognitive deficits; therefore, blood glucose goals are typically higher for this age group 1
- Assess for hypoglycemia frequency and awareness at every clinical visit 1
Emerging Treatment Options
- Intranasal glucagon (3mg) is now approved for treatment of severe hypoglycemia in patients ≥4 years of age and offers easier administration compared to injectable glucagon 6
- Continuous glucose monitoring systems with or without partial closed-loop insulin delivery can help prevent hypoglycemic episodes 7
By following this structured approach to hypoglycemia management, clinicians can effectively treat hypoglycemic episodes while minimizing complications and improving quality of life for pediatric patients with diabetes.