LWD - Chapter D
Low & High Glucose Levels
D1: Low blood glucose levels (Hypoglycaemia)
Hypoglycaemia - what is it? How to recognise and treat with confidence.
In someone without diabetes, the body is able to balance the blood glucose (BG) level between 3.5 and 7mmol/L the majority of the time. In Type 1 diabetes, where insulin is injected either by pen or pump it is much harder to keep the BG between this narrow range.
In diabetes we define Hypoglycaemia (Hypo’s) as a BG level goes below 3.9mmol/L or with newer technologies such as Continuous Glucose Monitoring (CGM) Sensors and Automated Insulin Delivery systems glucose levels between 3.6 and 8 mmols/L are increasingly possible.
If your child is wearing a sensor which is reading in the target range but they feel Hypo a finger prick glucose check should be carried out.
How will you know if your child is having a hypo?
Your child may experience some of these sensations as the body tries to correct the hypo:-
- Shaking.
- Pounding heart.
- Hungry.
- Sweating.
- Dizzy.
- Feeling weak.
The effect of low BG levels on the brain means that it may then become:-
- More difficult to concentrate or perform skills or they may complain of a headache.
- Their behaviour may also seem different to usual.
You may notice they seem more:-
- Irritable.
- Tearful.
- Quiet.
- Drowsy or Uncooperative.
- Pale.
What sort of things can cause a hypo?
- Too much insulin - too large a dose or too many doses in too quickly “insulin stacking”.
- Being more active than usual.
- Not eating or drinking as much as usual – perhaps missing a meal or loss of appetite.
- After drinking alcohol.
- Stress.
- Hot weather.
- Lipohypertrophy or lumpy injection sites.
Hypoglycaemia at night time
Some children have hypos at night without it disturbing their sleep, so can be more difficult to detect.
If they have a number of hypos this can also affect awareness so identifying and preventing them is important. Bedtime glucose levels do not necessarily predict the glucose overnight so checks around 2-3am may be recommended by your diabetes team.
If your child has exercised in the afternoon or early evening hypos later in the evening or overnight (approx. 7-11 hours later) can be more likely so checking overnight can be helpful.
The amount of Hypo treatment needed will vary according to the insulin regime.
- If using Multiple daily injections or Pump therapy in “Open loop” 0.3g/kg is advised.
- If in using AIDs in Auto mode or Smartguard 0.15g/kg is advised.
Below you can see the usual amounts of fast acting glucose required for children of different ages. This will raise BG level by about 3-4mmols.
Lift Glucose Shot:
- 10mls = 2g Glucose
- 10-15mls = 3g Glucose
- 20mls = 5g Glucose
- 30mls = 8g Glucose
- 40mls = 10g Glucose
- 60mls = 15g Glucose
Lift Glucose Tablets (1 tablet contains 4g):
- 1/2 tablet = 2g Glucose
- 1 tablet = 5g Glucose
- 2 tablets = 8g Glucose
- 2-3 tablets = 10g Glucose
- 4 tablets = 15g Glucose
Lucozade Energy Tablets (1 tablet contains 3g):
- 1 tablet = 3g Glucose
- 2 tablets = 5g Glucose
- 3 tablets = 8g Glucose
- 3-4 tablets = 10g Glucose
- 5 tablets = 15g Glucose
Dextrose Energy Tablets (1 tablet contains 3g):
- 1 tablet = 3g Glucose
- 2 tablets = 5g Glucose
- 3 tablets = 8g Glucose
- 3-4 tablets = 10g Glucose
- 5 tablets = 15g Glucose
Fruit Pastilles (1 sweet contains 3g):
- 1 sweet = 2g Glucose
- 1 sweet = 3g Glucose
- 2 sweets = 5g Glucose
- 3 sweets = 8g Glucose
- 3-4 sweets = 10g Glucose
- 5 sweets = 15g Glucose
Haribo Treat Size (1 bag contains 12g CHO):
- 1/4 bag = 2g Glucose
- 1/4 bag = 3g Glucose
- 1/2 bag = 5g Glucose
- 3/4 bag = 8g Glucose
- 1 bag = 10g Glucose
- 1 bag = 15g Glucose
Chocolate is not recommended for hypos.
This is because it contains fat which slows the absorption of glucose, and lactose which is a more slowly absorbed carbohydrate so your child will likely take longer to recover.
Fructose (fruit sugar) is absorbed slightly slower than glucose but not as slowly as lactose. It may be an option if apple or orange juice is more acceptable, and you find it works quickly enough.
In the case of a severe hypo
This is a rare occurrence which can lead to loss of consciousness and/or seizure and requires assistance by another person to administer an intramuscular injection of Glucagon.
If you would like to refresh skills in how to do this at any time please contact the diabetes team. You can also watch the short video on how to administer this intramuscular injection.
As young children are less able to communicate their needs, they are slightly more at risk of a severe hypo however the incidence of this has fallen significantly over the last 20 years and optimal glycaemic control can reduce the risk of severe hypos, In addition AIDs have further reduced this risk.
How To Give An Injection Of Glucagon
This short film shows you how to give an injection of glucagon
The aim is to support CYP and families to feel confident recognising and treating hypos so that they have the least impact on everyday life.
Key points to consider:
- Prompt treatment can prevent severe hypos.
- Make sure there is always a supply of glucose tablets or sugary drinks.
- Monitoring blood or sensor glucose levels regularly to reduce the risk of hypos.
- Encourage children and young people to let their friends know that they have diabetes and know what to do in the event of a hypo.
- Wearing some form of identification is a good idea.
- Consider whether this a one-off event or is there a pattern of low glucose levels?
- Try to work out the cause so you can try and prevent hypos in the future.
- Monitor more frequently during the next 24 hours following a hypo.
- Monitor glucose and ketone levels 2-4 hourly if hypo, hyper or ill.
- 2-3 mild hypos per week are not unusual when diabetes is well managed and glucose levels are close to target.
D2: High blood glucose levels (Hyperglycaemia)
Why do I need to treat high blood glucose levels?
Achieving target glucose levels of 4-10mmols/L over 70% or (16hours of each day) and before meals a narrower target of 4-8mmols/L is recommended to reduce the risk of acute and long-term complications of diabetes and minimises effects on learning, feelings and quality of life.
High glucose levels can make a person feel unwell in the short term (eg thirsty, less able to concentrate, irritable) and if this happens regularly can lead to a raised HbA1c.
Thinking about possible reasons for this happening, noticing patterns on your CGM or the Glooko or Medtronic Carelink data platforms and contacting the diabetes team to discuss can help to actively find solutions promptly.
Common reasons for high glucose (above 8 mmols/L) may be:
- Mis-match of insulin to food - timing or dose Missed Insulin.
- Growth / puberty / hormones/ menstruation Sugary foods/ drinks.
- End of honeymoon/ remission phase Stress/ Exams.
- Illness (see J section: Ketones and diabetes) Reduced activity.
Managing Hyperglycaemia with different insulin treatments
High Glucose Values:
- Multiple Daily Injections = Glucose > 9-14mmols.
- Pump Therapy (not closed loop) = Glucose > 9-14mmols.
- Hybrid Closed Loop (HCL) pumps = Glucose >14mmols.
Check:
- Multiple Daily Injections = Check when last insulin dose given.
- Pump Therapy (not closed loop) = Check that infusion set/POD is still attached to the body, no leakage and that there are no alarms indicating an issue with insulin delivery.
- Hybrid Closed Loop (HCL) pumps = Check that infusion set/POD is still attached to the body, no
leakage and that the system is running in automated mode and that there are no alarms indicating an issue with insulin delivery.
Check Glucose 9-14mmol/L:
- Glucose trend / sensor arrow – If downward review in 2hrs for Injections, or 90mins for Pump therapy or Hybrid Closed Loop.
- Glucose trend / sensor arrow – If absent or upwards on Pump / Hybrid Closed Loop check that infusion set is still attached to the body, no leakage and no alarms indicating an issue. If HCL check in automated delivery.
Check Glucose >14mmol/L, Blood Ketones >0.6mmol/L (positive):
- Contact diabetes team for dose advise if unsure.
- Will require additional insulin via an insulin injection pen device.
- Will require infusion set / POD change immediately.
- No physical activity until ketones have cleared.
- If on HCL put pump into manual mode for 2 hours to prevent additional auto corrections.
Check Blood Ketones >0.6mmol/L (positive):
- Contact diabetes team for dose advise if unsure.
- Will require additional insulin via an insulin injection pen device.
- Will require infusion set / POD change immediately.
- No physical activity until ketones have cleared.
- If ketones >0.6 and drowsy, vomiting abdominal pain, breathing heavily dial 999.
Check; Blood Ketones <0.6mmol/L (negative):
- Multiple Daily Injections = Give correction injection using calculator app to calculate dose.
- Pump Therapy (not closed loop) = Enter sensor/blood glucose into pump calculator. Deliver any bolus proposed.
- Hybrid Closed Loop (HCL) pumps = Check and deliver any bolus proposed by the bolus calculator within the HCL pump.
Retest/Recheck:
- Multiple Daily Injections = Retest blood/Recheck sensor glucose after 2 hours.
- Pump Therapy (not closed loop) & Hybrid Closed Loop (HCL) pumps = Retest blood/Recheck sensor glucose after 90 minutes.
Action:
- Multiple Daily Injections = If the glucose level is lower than the previous value, no further action is required. If glucose level is the same as, or higher than the previous value, give another correction injection of insulin, if advised by the bolus calculator.
- Pump Therapy (not closed loop) = If glucose remains greater than 14mmol/L, change infusion set/POD. After infusion set/POD change enter sensor/blood glucose into pump calculator.Deliver any bolus proposed.
- Hybrid Closed Loop (HCL) pumps = If glucose remains greater than 14mmol/L change infusion set/POD. After infusion set/POD change, check and deliver any bolus proposed by the bolus calculator within the HCL pump.
Retest/Recheck:
- Multiple Daily Injections = Retest blood/Recheck sensor glucose after 2 hours. If the glucose level is lower than the previous value, no further action is required.
- Pump Therapy (not closed loop) & Hybrid Closed Loop (HCL) pumps = Retest blood/Recheck sensor glucose after 90 minutes. If the glucose sensor is showing downward arrows and/or the glucose value is lower than the previous value, no further action is required. If on HCL restart automated mode.
How do I work out how much correction insulin to give?
If glucose levels are above target, your meter/pump bolus calculator will automatically increase the dose of insulin needed to match both carbohydrates eaten and to bring the glucose level back down to target range.
What is ‘Active insulin’ (AIT) or ‘Insulin on board’ (IOB)?
Both terms are essentially the same thing and refers to how much insulin is still working from previous insulin injections, infusions or boluses. It is a safety feature to prevent over correction of high glucose levels. If you have IOB or AIT the calculator may reduce or eliminate a correction dose to avoid the insulin “stacking” (giving too much insulin too close together) which could lead to hypos. Having high glucose levels immediately after meals does not necessarily mean you need more insulin, as the insulin given may still be working to bring the glucose level down.
AIT or IOB in CYP is usually set at 2 to 3 hours as smaller boluses mean the majority of the bolus will be used in this time.