"Severe hypoglycaemia in children and adolescents should have already died out, just like the dinosaurs did more than 60 million years ago," said a young student recently in one of the author’s training sessions. Despite new and improved insulins, pump therapy, improved training and better modes of treatment, they still exist, these hypos. What do you do when blood sugar levels drop too far? This article is about conquering the fear of hypoglycaemia.  

Hypoglycaemic events are still amongst the main fears that accompany insulin therapy. They are unable to be completely avoided in type 1 diabetes, no matter what the mode of therapy. One of the best ways, however, to protect oneself is to have one’s therapy frequently reviewed by the physician. Another is by recognizing the signs, causes and characteristics of hypoglycaemic events, for which one can be educated (hypo-trainings). Hypo-training also serves to improve safety and to teach the appropriate procedures to be carried out according to severity and, according to the age of the patient. This is especially important for children and adolescents.  

Are hypos dangerous?
Do hypos cause only temporary problems? Do they cause permanent damage? Can they even be life threatening? Researchers say: Severe hypoglycaemic events should be avoided, especially in children under six years of age. The danger of severe hypos lies in the fact that children are helpless and can injure themselves if they occur when, for instance, riding on a bicycle. Today, it is assumed that permanent effects on intelligence or performance do not necessarily occur as a result of a severe hypoglycaemic event.
For many children, and especially adolescents, hypos represent an embarrassing inconvenience, particularly if they occur in front of friends. Furthermore, after a severe hypo, very high blood sugar values are more accepted in order to avoid another such episode. Consequently, subsequent metabolic control is often neglected as a result.  

Mild hypoglycaemia  
Hypoglycaemia is categorized into three types: mild, moderate, and severe. In mild cases of hypoglycaemia, the blood sugar gradually drops a little bit too low (90–100 mg/dl or 5–5.6 mmol/l), or drops suddenly from, for instance, 200 down to 120 mg/dl (11.1 to 6.7 mmol/l). In both these scenarios, the child remains fully alert and behaves normally. Some kids don’t even feel it. Others realize it straight away. Parents can recognize approaching hypoglycaemia by, for example, a gradual change in facial colour, a reduction in activity, or slight mood changes. 
Moderate hypoglycaemia, on the other hand, is easier to recognize for most children and adolescents than mild hypoglycaemia. In moderate hypoglycaemia, the blood sugar drops to between 70 and 80 mg/dl (3.9–4.4 mmol/l).

Alarm signals for moderate hypos
Warning signs tend to signal an approaching hypo. When one recognizes them and takes notice of them fast enough, they can prove to be very useful. In the case of moderate hypos, the child can usually speak, and react to instructions. Moderate hypos negatively affect concentration, agility and feelings. A moderate hypo requires urgent treatment: with dextrose, a carbohydrate drink or a carbohydrate-rich piece of food. Young children need assistance with a moderate hypo, in order to make sure enough carbohydrate is consumed early enough.

Severe hypoglycaemia
At blood sugar levels of between 50 and 60 mg/dl (2.8–3.3 mmol/l), a child is said to be experiencing severe hypoglycaemia. Even adolescents cannot recover from a severe hypo without assistance. The child is not be in the position to respond to instructions, may not be able to swallow properly, may experience cramping, or temporarily lose consciousness. In such cases, the child needs an emergency injection (glucagon), or one calls the doctor. It is for this reason that a household emergency kit (‘hypo kit’) should be on hand, and regularly maintained. It is a good idea to practice using such a kit on an outdated one, or ask your diabetes consultant to refresh your memory. You must know exactly what to do in an emergency situation, because a severe hypoglycaemic event in your child is quite a stressful experience.  

Signs change
The body seems to know when the blood sugar has dropped to a certain level. In order to avoid a further drop, hormones such as adrenaline are released. If diabetes has been present over a long period of time, however, these reactions minimize, making it harder to recognize when the blood sugar has dropped too far. Moreover, the child becomes accustomed to these signals and is less prone to take immediate action. In this way, children and adolescents can miss the signals. The blood sugar can drop without being noticed. After many years, the signs of hypoglycaemia can be very different to what they were at the beginning of the diabetes. Children and adolescents often pay so much attention to the signs at the beginning of the diabetes, they become anchored. In this way they are often unable to recognize the new signs. In this case, detective work is called for: one must try to find the new signs that the child feels, but not yet associates with low blood sugar. 

A three-tiered, at-home training that can be carried out by parents and children brings more security. Firstly, one learns to recognize the tell-tale signs. What is my body trying to tell me? Secondly, one tries to answer the question as to where and when I should be especially cautious. Thirdly, what should I do when I feel the signs of approaching hypoglycaemia. These three points build a chain of security that enables the prevention of severe hypos.
One can only recognize signs when one knows what they are. Imagine that you can see all your impressions on a radar screen. The screen would be full of signals, from which you must decide which one to react to.

Not on the radar screen
A child, for example, is in the middle of building a toy house with his friends. He is fully absorbed. On his own ‘radar screen’, he sees only the building plan and the tools. Somewhere there is a faint light blinking which says ‘I’m not feeling too good’, or ‘hungry’, but these signals are blotted out by the others. Similar to this is the school child busying himself with his homework so he can join his friends. A faint signal indicates ‘shaky writing’ or ‘can’t concentrate’, but his attention is on finishing. Parents can also miss faint signals on their radar screens. If the child tramps into the house with muddy shoes, that slight loss of colour around the nose that the child normally gets with low blood sugar is overlooked. One needs, therefore, to pay attention and to become familiar with the signs in order to recognize low blood sugar in all circumstances. 

Of lists and stick men
Listing out the physical signs helps one to recognize hypos. The child will be motivated to think about the signs, and through writing them down, will better remember them. In addition, parents, teachers and physicians can look out for these signs at all times. This list should be overhauled and updated around twice a year. Little role plays can be a fun way to learn these signs, free of anxiety.
Stick men can be a highly useful tool for very young children to illustrate bodily signals. The stick man is coloured in, in the place where the child feels low blood sugar the most. Discuss these sketches with the child! In this way, young children learn to be able to name their bodily signals.

Pay attention and react
Well known signs can often be felt differently according to the circumstances. Some children notice their signs better when they are at rest, others when they are moving. One can register how each situation affects these physical signs (see table on left). In this way, critical situations can be recognized. 
At the beginning of a hypo, one must react. This includes a blood sugar measurement. In severe cases, however, one should administer something to eat/drink straight away, before measuring.  

But then it happens 
If a hypo does occur, it should subsequently be discussed between parents and children, and also with the experts. The child should never be under the impression that the hypo was his fault. One should pay less attention to finding the guilty party, and more on finding a characteristic pattern. Hypos don’t happen just like that. What preceded it can provide important information towards avoiding further episodes. If children find it difficult to read bodily signals, special hypo-training sessions can be carried out in which exactly that is practiced. Such steps should be practiced at home, leading to a safer and easier daily routine.

Contact
Béla Bartus, Dip. Psych.
Diabetes Psychologist DDG
Stuttgarter Clinic
Paediatric Clinic, Olga Hospital
E-Mail: b.bartus@olgahospital.de