How to manage hypoglycaemia

This guide is to help you and your family and friends recognise and treat low blood glucose or sugar in Type 1 Diabetes (low blood sugars are 3.9mmol/l and below). We will refer to it as blood glucose from now on.

When should I call for help?

You should call for help if:

• you or your parents or carers are worried
• you are having hypos repeatedly or at the same time each day
• nocturnal hypos are a regular problem
• you think you are losing your awareness of hypos

What is it hypoglycaemia?

Hypoglycaemia is the medical name for a blood glucose level 3.9mmol/l or below. An easy way to remember this is ‘four is the floor’.

• ‘hypo’ means low
• ‘glyc’ means glucose or sugar
• ‘aemia’ – blood

It is often called a ‘hypo’ for short. It is caused by a mismatch between insulin dose and the food eaten or activity. It usually happens for a reason and you should be able to work out why it happened.

Why did it happen?

Possible reasons for a hypo happening include:

• Had you already injected for your meal but then ate less than you were expecting to eat?
• Did you get the carbs wrong or guess them?
• Did you forget to check your blood glucose before your meal and gave insulin for the food not knowing if you were already a bit low?
• Did you have an active time before the meal or snack but still gave the full amount of insulin?
• Have you had a few hypos already before this one?

Hypos are defined in 3 levels of severity:

• Mild which can be self treated
• Moderate where help is needed to treat the hypo
• Severe where you may be partly conscious or unconscious and Glucagon may be needed to treat you. You should not take anything by your mouth.

What are the warning signs?

Warning signs include:

• shakiness
• feel dizzy
• sweating
• irritable
• hunger
• tingling of lips
• anxiety
• irritability
• aggressive behaviour
• not able to concentrate
• headache
• tiredness and be yawning
• paleness
• glazed eyes
• confusion or not able to speak properly

What do I need to do?

Act quickly. Stop what you are doing and treat the hypo. A hypo should be treated with fast acting carbohydrate which provides the body with immediate glucose. Ignoring your hypo will not make it go away. Quick action can prevent severe hypos.

Encourage your child to let someone know quickly if they are feeling low. Make sure responsible carers know what to do.

Carry an ID card or jewellery if they can.

Treating mild and moderate hypos

Test your child if possible, and if their blood glucose is below 3.9mmol/l, treat with 5g to 15g of fast acting sugar. As a guide, around 0.3g of glucose is needed per kg of body weight.

For example:

• 5g of glucose is needed for a 10kg child
• 10g of glucose is needed for a 30kg child
• 15g of glucose is needed for a 50kg child

This is only a guide and your child may need more or less glucose depending on the circumstances. If your child has been very active or has recently had insulin or a change in their dose then you need to take this into account.

What can we use and how much?

* You need more fruit juice as it contains the fruit sugar fructose and will take longer to be absorbed.

If you are struggling to get your child to eat or drink, use a tube of Glucogel which supplies 10g of glucose.

Do not use chocolate as it does not work quickly enough. Chocolate contains lactose which is a slow release sugar and the fat in chocolate also slows down digestion. For the same reason milk is not a good hypo treatment.

For the following, give your child an extra 20g of carbs:

• Pre and post exercise
• Insulin overdose
• After alcohol

What do I do next?

Recheck your child’s blood glucose levels after 10 minutes. If the blood glucose level is still 3.9mmol/l or lower, then repeat the fast acting glucose and repeat blood glucose test after 10 minutes. If the blood glucose test is 4mmol/l or above then take your next meal or snack, if due.

Treating severe hypos

These require help or assistance from someone. In this case the blood glucose level becomes even lower and this can cause loss of consciousness, or a seizure (fit). Your child may start screaming, be uncooperative or may start twitching.

Severe hypos are not common but you need to know what to do should it occur:

• Do not give an unconscious person anything by mouth.
• Place your child in the recovery position: lying on their side with their head tilted back.
• If your child is on a pump, stop this immediately.
• At diagnosis you will have been given an orange box containing a synthetic form of Glucagon (GlucaGen). You will also have been advised how to use it.
• If your child is unconscious you should administer the GlucaGen immediately.

If you do not feel able to do this you should call 999.

Night hypos

These are feared by all parents. Low blood glucose levels are not uncommon and your child will not always be disturbed by them.

When blood glucose levels drop the body responds by releasing other hormones which will result in the release of glucose from the liver. This will mean in the morning you may see a high rather than low blood glucose level and your child may complain of a headache.

Tips for reducing the risk of night hypos:

• always check blood glucose before bed.
• if your child has low readings at bedtime or repeatedly high blood glucose readings in the morning, check their blood glucose at 2 to 3am to see if they are dropping during their sleep. The reading at 3am should be >5 mmol/l. Do not do this every night.
• following exercise during the day consider reducing ratios of insulin with subsequent meals or snacks.

Learn from previous experiences.

Why did it happen?

Hypos usually happen for a reason, if you think back to what was happening before it you can sometimes work out why it occurred.

Possible causes include:

• too much insulin
• not enough carbohydrate food
• unplanned activity or exercise
• delayed meal
• change in insulin treatment
• illness
• hot weather
• stress
• injecting into muscle instead of the fatty layer under your skin.
• alcohol

Mild or moderate hypos are quite common and can be a sign that your blood glucose levels are within range most of the time.

Frequent hypos or hypos at certain times of the day or on a particular day suggest there is a mismatch with food, activity and insulin.

What if my child is on a pump?

If you are on an insulin pump then consider the basal rate doses especially after sport. Think about setting up a second basal rate if you do regular sports. Speak to the team if you need help to do this.

If you are on injections you may want to reduce the doses of insulin with your next meal.

Longer acting carbohydrate

It can be easy to over treat hypos which can result in a high blood glucose level and so we no longer routinely suggest starchy carbohydrate in addition to the fast acting carbs.

Ideas for ID

There are lots of different medical alert items for sale which include things such as a plastic ID card or jewellery. Please ask the diabetes nurses or dieticians for a card, or look online for medical alert jewellery. There are a variety of products bracelets, necklaces and so on, made of metal, silicon type bands, beads and so on.

The most important thing is that your child will wear it.

Checklist

• Always carry dextrose, or have it at school where you can get it easily
• Keep your testing kit with you
• Test your blood glucose regularly
• Carry ID: card or bracelet with emergency contact number
• Always test before and after sport or activity
• Make sure responsible adults and friends know how to recognise and help with a hypo
• Replace any used hypo kit promptly, you may need it sooner than you think
• Have hypo kit in the car, at school, and at any friends or family you visit regularly.
• Ask team for help if you or your child have any concerns, questions or need to revisit any of the above

If you realise your child is becoming less aware of their hypos then do let the team know as this can be addressed. It is known as hypo unawareness. Very tight control can result in the symptoms being missed and it is important that hypo recognition is restored as a child can lose confidence quickly and parents and carers are understandably anxious. Generally 2 to 3 weeks of higher blood glucose levels will make sure the warning signs are back.

Do discuss any blood glucose patterns you are unhappy with at your clinic appointment to try to address them.