Updated July 20, 2006

Be Aware of Hypoglycemia Unawareness

by Karen Kelly, R.N., B.S.N., C.D.E., and Amy Gilliland, R.N., M.S.N., C.D.E.

Anyone whose child uses insulin has no doubt been warned of the dangers of hypoglycemia (low blood sugar) and the need to treat it promptly. Mild hypoglycemia can cause a person to feel uncomfortable and can interfere with his normal functioning. Severe hypoglycemia can cause seizure, loss of consciousness, and coma. To prevent severe hypoglycemia, most people with diabetes are advised to treat for hypoglycemia—by ingesting some carbohydrate—when their blood sugar level is 70 mg/dl or lower. At bedtime or during the night, treatment is recommended when blood sugar is below 80 mg/dl.

Regular blood sugar monitoring can help your child avoid hypoglycemia, and so can paying attention to how he feels. Any symptoms of hypoglycemia should prompt you or him to check his blood sugar level and treat for hypoglycemia if necessary.

Not treating for hypoglycemia when blood sugar is low can have some serious consequences, among them severe hypoglycemia and, over time, the development of hypoglycemia unawareness. A person with hypoglycemia unawareness either can no longer recognize his lows or his body no longer exhibits the early warning symptoms of low blood sugar. As a result, he may develop severe hypoglycemia with no warning, possibly with disastrous results. Hypoglycemia unawareness can happen in children and adults, but it is both preventable and treatable.

Clueing in to signs and symptoms
Typical symptoms of hypoglycemia include sweating, shaking, weakness, having a headache, dizziness, and hunger. Hypoglycemia can also cause emotional symptoms such as irritability or, in some cases, giddiness. In young children, signs of low blood sugar may include crying, lethargy, pallor, glassy eyes, sleepiness, or a lack of coordination. Generally, a child will exhibit the same symptoms each time he has low blood sugar.

Since infants and very young children cannot identify signs of hypoglycemia or verbalize their symptoms to their caregivers, it’s important for parents and caregivers to notice these signs and act accordingly. Although they may be unaware of a symptom’s significance, some toddlers will verbalize symptoms by saying, for example, “I want juice” or “I’m hungry.” A preschooler may say he feels tired or that his stomach or legs feel funny. By about age six, most children can be expected to recognize symptoms of low blood sugar, understand that what they are feeling is related to low blood sugar, and understand that they need to take some action to feel better.

If your child does not verbalize any symptoms when he has low blood sugar, you can help him start to recognize symptoms by asking if he noticed any different or funny feeling just before you checked his blood sugar after a low has occurred. This sort of discussion can help even small children make the connection between their feelings and low blood sugar and can reinforce the importance of their saying something when they have symptoms.

While each person generally has the same symptoms each time he has low blood sugar, it’s still possible to occasionally have other symptoms. For example, nightmares, restless sleep, slow reaction time, and numbness around the mouth can be unusual signs of low blood sugar. Even doing poorly in school can be a sign of undetected hypoglycemia.

Mark, a junior high school student, had always done well in math, but suddenly he was struggling and his grades were slipping—even though he was putting in as much effort as he always did. His diabetes educator suggested that he check his blood sugar level for several days just before the math class. To his surprise, he found that he was low before class three days in a row, but he hadn’t noticed any of his usual symptoms at these times. Once his insulin dose was adjusted to correct the lows, his grades improved, and the experience served as a reminder that blood sugar can be low with no symptoms or with only very subtle symptoms that are easy to ignore.

Karen Kelly and Amy Gilliland are pediatric diabetes educators at the Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania.

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