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.

But a symptom of hypoglycemia doesn’t have to be unusual to go unnoticed. Even when children experience their usual symptoms, they may not notice them if they are very involved in an activity. Children also sometimes ignore the signs and symptoms of low blood sugar so they can continue with their chosen activity, or they may not speak up because they feel too embarrassed to let someone know that they are low. This sometimes happens when they are with people they do not know very well or are at school. The trouble is, if they ignore the low too long, it can turn into a severe low, resulting in loss of consciousness or seizure. And if they ignore even mild lows too frequently, they can develop hypoglycemia unawareness.

Preventing hypoglycemia
When a person has frequent episodes of hypoglycemia, his body becomes accustomed to being low, and he no longer experiences symptoms of hypoglycemia at the same blood glucose level. In other words, he develops hypoglycemia unawareness. The first step toward preventing hypoglycemia unawareness, therefore, is to prevent even mild episodes of hypoglycemia.

For parents of young children, prevention efforts include explaining the importance of letting an adult know quickly about any signs or symptoms of low blood sugar. It may be necessary to repeat this information more than once to reinforce it. Parents of older children and teens may also need to remind their children of the importance of treating low blood sugar quickly, since diabetes may not come at the top of a child’s or teen’s list of priorities.

One of the most important tools for preventing low blood sugar is frequent blood sugar monitoring. Most diabetes professionals recommend monitoring a child’s blood sugar a minimum of four times a day—before each meal and at bedtime. In addition, checking before, during, and after exercise is important to see how exercise affects a child’s blood sugar level. It may be necessary to add a snack before or after exercise or alter a child’s insulin doses on the days he exercises to prevent hypoglycemia.

Who checks a child’s blood sugar level—parents, another caregiver, or the child himself—will depend on a child’s age and maturity level, among other things. Even if a child can check his own blood sugar level, it works best if parents remain involved, offer emotional support, help with insulin adjustments and other tasks when needed, and generally make sure blood sugar monitoring gets done.

For some children, middle-of-the-night blood sugar monitoring is recommended in addition to regular daytime monitoring. If a child has a history of severe low blood sugar during the night, it may be advisable to check blood sugar levels at midnight and at 3 AM routinely once a week. This is a challenging task for parents, but it can help a lot to see patterns and to determine whether treatment adjustments are working. It is also a good idea to check nighttime blood sugar levels after a day of heavy exercise or physical activity, because a child may have delayed hypoglycemia several hours after exercise has ended. Middle-of-the-night blood sugar levels should also be checked if your child is low at bedtime. Rechecking allows you to see whether treatment of the bedtime low (with a snack) was sufficient.

Teens who are learning to drive should be instructed (and reminded) about another important time to check their blood sugar: before they get behind the wheel of a car. Since most teens value the freedom that having a driver’s license represents, reminding them that their license may be revoked if they fail to practice safe driving may help this important lesson sink in.

Another strategy to help prevent hypoglycemia is to keep meal and insulin times consistent, with no more than half an hour of difference for insulin injections and mealtimes from one day to the next. This may be less important for children who use an insulin pump (since a bolus can be delayed until food is ready to be eaten) or inject insulin glargine (brand name Lantus), which has no peak. But sticking to a meal schedule makes good, common sense for other reasons, including avoiding getting too hungry and then getting cranky or overeating when the meal finally takes place. It is also usually recommended that meals have about the same amount of carbohydrate from day to day to help with blood sugar control.

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

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