What are the recommended treatment steps for hypoglycemia in adults versus children, including oral rapid‑acting carbohydrate dosing for conscious patients, intravenous dextrose dosing for those with IV access, and glucagon administration for patients without IV access or who are unconscious?

Hypoglycemia Treatment: Adult vs Pediatric

Conscious Patients Who Can Swallow

For both adults and children who are conscious and able to swallow, immediately administer 15–20 g of oral glucose tablets (chewed and swallowed), which is the gold-standard first-line treatment. 1

Adult-Specific Oral Treatment

• Pure glucose tablets provide the most rapid and predictable glycemic response, raising blood glucose approximately 40 mg/dL with 10 g or 60 mg/dL with 20 g within 30–45 minutes. 1
• If glucose tablets are unavailable, dissolve 15 g of glucose in 150 mL of water and administer orally as an equivalent dose. 2
• Never use buccal or sublingual routes in adults who can swallow—swallowed glucose yields significantly higher plasma glucose concentrations at 20 minutes compared to buccal administration. 1
• Do not use 40% dextrose gel as initial treatment in adults who can swallow; it adheres to oral mucosa and provides no advantage over tablets. 1

Pediatric-Specific Oral Treatment

• Oral/swallowed glucose tablets or solution remain the gold-standard for conscious children who can swallow. 2
• For uncooperative children who refuse to swallow but are still conscious, place a granulated-sugar slurry under the tongue (sublingual administration). 2
• When tablets are unavailable or the child is uncooperative, 40% dextrose gel (approximately 200 mg/kg as a single dose) massaged into the buccal mucosa is an acceptable pediatric alternative. 2

Monitoring Protocol (All Ages)

• Check blood glucose before treatment if possible, then administer glucose immediately. 1
• Recheck blood glucose at 15 minutes; if still below 70 mg/dL, repeat the 15–20 g dose. 3, 1
• Once blood glucose returns to normal, provide a meal or snack to prevent recurrence. 3

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Unconscious or Unable-to-Swallow Patients

For patients who cannot swallow or are unconscious, never attempt oral glucose administration due to aspiration risk—use intravenous dextrose if IV access is available, or intramuscular glucagon if not. 2, 4

Intravenous Dextrose (Preferred When IV Access Available)

Adult and Pediatric Dosing

• Administer 10% dextrose intravenously in 5-g aliquots (approximately 50 mL) over 1 minute, repeating every minute until symptoms resolve or blood glucose exceeds 70 mg/dL, with a maximum total dose of 25 g. 2
• Use 10% dextrose rather than 50% dextrose—it achieves comparable symptom resolution (96% vs 89%) with zero adverse events (0% vs 4%) and lower post-treatment hyperglycemia. 2, 5
• Expect an approximate increase of 4 mg/dL per gram of dextrose administered, though a 25-g bolus can raise glucose by roughly 160 ± 30 mg/dL at 5 minutes, often causing over-correction. 2

Critical Management Steps

• Immediately discontinue any insulin infusion when treating hypoglycemia to prevent recurrent episodes. 2
• Check blood glucose immediately before the first IV dose and re-measure at 15 minutes; repeat treatment if glucose remains <70 mg/dL. 2
• During any ongoing insulin infusion, monitor glucose every 1–2 hours to detect recurrent hypoglycemia. 2

Glucagon Administration (When IV Access Unavailable)

Adult Dosing

• Administer 1 mg intramuscular or subcutaneous glucagon as a safer alternative for unconscious patients without IV access. 2
• Onset of action is 5–15 minutes; nausea may occur as a side effect. 2, 6
• Recovery of consciousness is 1–2 minutes slower after glucagon than after intravenous glucose. 6

Pediatric Dosing

• Emergency glucagon kits require a prescription and should be available to family members, school personnel, and child care providers. 3
• Activate emergency services immediately for any infant who cannot swallow, is not awake, or is seizing—infants <6 months are at higher risk and warrant a lower threshold for activation. 2
• Non-healthcare professionals can safely administer glucagon; ensure unexpired kits are available. 3

Glucagon Efficacy and Alternatives

• Glucagon failure rate ranges from 0% to 14.4% in most studies, with effectiveness not significantly different from dextrose (OR 0.53,95% CI 0.20–1.42). 7
• If the first dose fails, a second dose can be administered. 7
• Intranasal glucagon formulations are similarly effective to intramuscular glucagon (OR 1.40,95% CI 0.18–10.93) and represent a major breakthrough in ease of administration. 7, 8

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Special Population Considerations

Pediatric-Specific Risks

• Prolonged or repetitive hypoglycemia ≤45 mg/dL (≈2.5 mmol/L) in children is associated with permanent neurological injury—prompt treatment is essential. 2
• Untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death. 4

Neurologic Injury Patients

• Treat blood glucose <100 mg/dL (rather than the usual <70 mg/dL) to protect vulnerable brain tissue. 2

Acute Ischemic Stroke

• Avoid hypotonic solutions such as 5% dextrose; use isotonic fluids to prevent worsening cerebral edema. 2

Diabetes Management Reassessment

• Any severe hypoglycemic episode requiring external assistance mandates a comprehensive reevaluation of the diabetes treatment plan. 3, 2
• Severe hypoglycemia independently raises mortality risk (OR ≈3.2,95% CI 2.25–4.64). 2

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Critical Pitfalls to Avoid

• Never give oral glucose to unconscious patients—the aspiration risk outweighs any benefit. 2, 4
• Do not add fat to carbohydrate-based treatment because it delays the acute glycemic response. 3, 1
• Do not add protein to carbohydrate-based treatment—it does not prevent subsequent hypoglycemia and may increase insulin response in type 2 diabetes. 3, 1
• Avoid using 50% dextrose as the first-line IV agent—it leads to more frequent over-correction, higher post-treatment hyperglycemia, and increased adverse events compared with 10% dextrose. 2, 5
• When transitioning from intravenous insulin to subcutaneous insulin, give subcutaneous insulin 1–2 hours before discontinuing IV insulin to prevent rebound hypoglycemia. 4