Incidence and predictive criteria of nocturnal hypoglycemia in young children with insulin-dependent diabetes mellitus

Porter, Paul; Keating, Barbara; Byrne, G C; Jones, Timothy W.

doi:10.1016/s0022-3476(97)70197-5

Cited by 110 publications

(71 citation statements)

References 16 publications

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“…It may be asymptomatic or be associated with subtle symptoms and signs, such as nightmares, restless sleep, low fasting blood glucose levels, and headache, confusion, or behavior changes on awakening. Bedtime blood glucose levels are poor predictors of nocturnal hypoglycemia (124).…”

Section: Hypoglycemiamentioning

confidence: 99%

Care of Children and Adolescents With Type 1 Diabetes

Klingensmith²,

et al. 2005

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Section: Hypoglycemiamentioning

confidence: 99%

Care of Children and Adolescents With Type 1 Diabetes

Klingensmith²,

et al. 2005

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“…However, near-normal glucose control is more difficult to achieve in pediatric versus adult patients with type 1 diabetes. DCCT adolescents had a higher HbA 1c and a greater risk of severe hypoglycemia than adults in the intensive treatment group (4), and very young children with type 1 diabetes have been shown to be at high risk for asymptomatic nocturnal hypoglycemia (5).…”

mentioning

confidence: 99%

“…Self-monitoring of blood glucose (SMBG) with multiple daily injections or insulin pump therapy (continuous subcutaneous insulin infusion [CSII]) offered the possibility of controlling postprandial hyperglycemia and reducing the risks of severe hypoglycemia. However, most youths with type 1 diabetes only measure premeal blood glucose levels during the day and rarely measure glucose levels during the night, the time of greatest vulnerability to hypoglycemia (5). Thus, marked glycemic excursions are undoubtedly missed by the brief glimpses into the 24-h glucose profiles provided by SMBG.…”

mentioning

confidence: 99%

Limitations of Conventional Methods of Self-Monitoring of Blood Glucose

et al. 2001

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OBJECTIVE -Children with type 1 diabetes are usually asked to perform self-monitoring of blood glucose (SMBG) before meals and at bedtime, and it is assumed that if results are in target range, along with HbA 1c measurements, then overall glycemic control is adequate. However, the brief glimpses in the 24-h glucose profile provided by SMBG may miss marked glycemic excursions. The MiniMed Continuous Glucose Monitoring System (CGMS) has provided a new method to obtain continuous glucose profiles and opportunities to examine limitations of conventional monitoring.RESEARCH DESIGN AND METHODS -A total of 56 children with type 1 diabetes (age 2-18 years) wore the CGMS for 3 days. Patients entered four fingerstick blood samples into the monitor for calibration and kept records of food intake, exercise, and hypoglycemic symptoms. Data were downloaded, and glycemic patterns were identified.RESULTS -Despite satisfactory HbA 1c levels (7.7 Ϯ 1.4%) and premeal glucose levels near the target range, the CGMS revealed profound postprandial hyperglycemia. Almost 90% of the peak postprandial glucose levels after every meal were Ͼ180 mg/dl (above target), and almost 50% were Ͼ300 mg/dl. Additionally, the CGMS revealed frequent and prolonged asymptomatic hypoglycemia (glucose Ͻ60 mg/dl) in almost 70% of the children.CONCLUSIONS -Despite excellent HbA 1c levels and target preprandial glucose levels, children often experience nocturnal hypoglycemia and postprandial hyperglycemia that are not evident with routine monitoring. Repeated use of the CGMS may provide a means to optimize basal and bolus insulin replacement in patients with type 1 diabetes.

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“…Both of these factors may have served to increase sensitivity to insulin (8) and decrease responsiveness to epinephrine. It is intriguing to speculate that decreased responsiveness to epinephrine may explain, in part, why younger age is an independent risk factor for severe hypoglycemia in clinical epidemiological studies of children with diabetes (9,10).…”

Section: Results -As Shown Inmentioning

confidence: 99%

Epipen as an Alternative to Glucagon in the Treatment of Hypoglycemia in Children With Diabetes

et al. 2001

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OBJECTIVE -Fear of a severe hypoglycemic reaction is a major obstacle to achieving nearnormal plasma glucose levels. Although parenteral glucagon is effective in treating these reactions, it is cumbersome to use, causes severe nausea, and is impractical in the school setting. Epinephrine is available as a premixed injection (Epipen) that may be used by all care providers. Using Epipen to treat hypoglycemia may be an effective, safe, and easy-to-use alternative to glucagon.RESEARCH DESIGN AND METHODS -Ten children (age 11.7 Ϯ 2.4 years) with type 1 diabetes were studied on two occasions. After an overnight equilibration period, hypoglycemia was induced via an insulin pump (1 mU ⅐ kg -1 ⅐ min -1 ). At a blood glucose level of 2.8 mmol/l, either glucagon (1 mg) or epinephrine (0.3 mg), in random order, was administered intramuscularly and responses were monitored.RESULTS -Plasma free insulin concentrations were similar in both studies. Plasma glucose levels increased by 1.7 Ϯ 0.2 mmol/l (mean Ϯ SEM) in 10 min and by 2.6 Ϯ 0.2 mmol/l in 15 min with administration of glucagon and were not consistently increased with administration of epinephrine (P Ͻ 0.01). Peak glucagon concentrations after administration of glucagon were Ͼ60-fold higher than basal concentrations. After administration of epinephrine, peak epinephrine levels were 20-fold higher than basal concentrations.CONCLUSIONS -Epinephrine does not seem to be an adequate substitute for glucagon in the treatment of severe hypoglycemia. The effectiveness of glucagon in reversing hypoglycemia and its side effects of nausea and vomiting are likely related to the markedly supraphysiologic plasma levels achieved with the standard intramuscular dose. Diabetes Care 24:701-704, 2001S evere hypoglycemia is the most frequent and feared acute complication of treatment of type 1 diabetes during childhood. In fact, fear of a severe hypoglycemic reaction has become a major obstacle in achieving lower glycosylated hemoglobin levels with intensive treatment. Parenteral injection of 1.0 mg glucagon is the standard treatment for a severe insulin reaction (1,2), but the need to reconstitute the hormone with diluent makes it difficult to use in an emergent situation. In addition, the standard dose of glucagon is often associated with severe nausea and occasionally with vomiting, which can complicate recovery from hypoglycemia by limiting the patient's intake of oral carbohydrate. Because glucagon can only be administered by a licensed health professional in many school systems, diabetic children may be precluded from field trips and other extracurricular activities for reasons of safety.Even though stimulation of epinephrine secretion is one of the main endogenous hormonal defenses against insulininduced hypoglycemia in type 1 diabetes, use of epinephrine for treatment of severe hypoglycemia in children has not been tested. This is surprising because a premixed and prefilled injection system for parenteral epinephrine administration is available for treatment of severe allergic reac...

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Incidence and predictive criteria of nocturnal hypoglycemia in young children with insulin-dependent diabetes mellitus

Cited by 110 publications

References 16 publications

Care of Children and Adolescents With Type 1 Diabetes

Care of Children and Adolescents With Type 1 Diabetes

Limitations of Conventional Methods of Self-Monitoring of Blood Glucose

Epipen as an Alternative to Glucagon in the Treatment of Hypoglycemia in Children With Diabetes

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