TOPIC:

Chapter 6

Low Blood
Sugar
(Hypoglycemia or
Insulin Reaction)

Prevention,
Detection, and
Treatment of
Acute
Complications
(hypoglycemia
low blood sugar)
TEACHING OBJECTIVES:
1. Present the symptoms, causes,
and treatment of mild,
moderate and severe
hypoglycemia.

H. Peter Chase, MD
Carolyn Banion, RN, MSN, CPNP, CDE

2. Identify the appropriate time to

contact the healthcare provider.

LEARNING OBJECTIVES:
There are two emergency problems in blood sugar control
for people with diabetes. The first, discussed in this chapter, is
low blood sugar or hypoglycemia. (The second, discussed in
Chapter 15, is high blood sugar or ketoacidosis.) Low blood
sugar comes on quickly and must be treated by the person,
family or friends. Early treatment helps prevent a more severe
reaction and possible hospitalization.

1. Define mild, moderate and

severe low sugar symptoms,
causes and treatment.
2. State the appropriate time to
contact a healthcare provider.

Any time a person has received a shot of insulin, or an oral

diabetes medicine, there is a chance of a low blood sugar
reaction. The family of a person with newly diagnosed diabetes
must know the signs and symptoms of hypoglycemia before
going home the first night.
A normal random (non-diabetic) blood sugar is usually
between 70-140 mg/dl (3.9-7.8 mmol/L). Normal fasting
values are usually between 70 and 100 mg/dl (3.9-5.5
mmol/L). For purposes of this book, we define a true low
blood sugar as < 60 mg/dl (< 3.2 mmol/L). The Amercian
Diabetes Association (ADA) defines a low blood sugar level as
any level < 70 mg/dl (< 3.9 mmol/L).

35

CAUSES OF LOW BLOOD

SUGAR

SYMPTOMS OF LOW BLOOD

SUGAR

Hypoglycemia (low blood sugar) occurs

because the body doesnt have enough sugar to
burn for energy. The level of sugar in the blood
falls too low. Sometimes it is called an insulin
reaction, a reaction or a low.

Usually the body gives a warning when low

blood sugar or an insulin reaction is developing.
DIFFERENT PEOPLE GET DIFFERENT
WARNINGS.

Frequent causes are listed below:

Meals and snacks that are late or missed
Extra exercise that burns more sugar than
usual
An insulin or oral medicine dose that is too
high
An insulin dose peaking at a different time
than usual
Giving a shot into muscle which results in
rapid absorption of insulin
Making a mistake in the drawing up and
giving of an insulin dose
Taking a bath or shower (or hot tub) soon
after taking a shot of insulin. (The blood
vessels in the skin dilate from the hot water
and cause insulin to be rapidly absorbed.) It
is always wise to wait at least 90 minutes to
take a shower, bath or hot tub after an
insulin shot. It is only necessary to wait a
short time (10-15 minutes) after being in
hot water to then do the shot.
Prevention of low blood sugars (lows) is
much wiser than having to treat the lows.
When too many lows occur, the stored sugar
and adrenaline (epinephrine) are drained.
When this occurs, the usual symptoms of a low
may not occur. In addition, over treatment
(eating too much) after a low can cause a high
blood sugar and can increase the HbA1c value
(Chapter 14). Paying attention to the seven
causes of lows listed above will help to decrease
the number of low blood sugars.

36

Chapter 6 Hypoglycemia (Low Blood Sugar)

These signs are the most common warnings

of an insulin reaction:
Hunger: the person may either feel hungry
or have an upset stomach (nausea)
Shakiness: the persons hands or body may
feel shaky
Sweatiness: the person may sweat more
than usual (often a cold sweat)
Color: the face may become pale,
gray or red
Headache
Confusion: the person may feel or look
spacey or may appear dazed

With an insulin
reaction, you may
experience confusion
or drowsiness.

Drowsiness: the person may yawn, feel

sleepy or may have trouble thinking clearly;
preschoolers frequently get sleepy
Behavioral changes: changes in behavior
are quite common; often the person may
cry, act intoxicated, or they act angry, or
they may feel weak or anxious
Double vision: the person may see double
or the pupils of the eyes may get bigger; the
eyes may appear glassy; the whites of the
eyes may look blood shot
Loss of consciousness
Seizure or convulsion: both loss of
consciousness and convulsion occur late in
the reaction. They are usually the result of
not treating a reaction quickly enough.
The first four initial symptoms (hunger,
shakiness, sweatiness and color) are due to the
output of the fight or flight hormone,
adrenaline (epinephrine is another name).
Later symptoms are more related to the lack of
sugar to the brain. Sugar is the main source of
fuel for the brain. If the low sugar continues
too long, the brain can be harmed. It is
particularly important to prevent severe low
blood sugar in young children. The brain
grows very rapidly in the first four years of life.

NIGHTTIME LOWS
People may wake up with symptoms (infants
may just cry) when lows occur during the night.
The symptoms may be the same as during the
daytime although there are sometimes special clues:
Inability to sleep or waking up alert,
hungry, restless, moaning, etc.
Waking up sweating
Waking up with a fast heart rate
Waking up with a headache
Sleep walking
Waking up feeling foggy-headed or with
memory loss

Low blood sugar, then an unusually high

blood sugar or positive urine ketones
(possible rebounding)
IF ANY OF THESE DO OCCUR,
TEST YOUR BLOOD SUGAR
IMMEDIATELY. If low, treat appropriately
and call the doctor or nurse the next day. Also
think about what was different the previous day
(extra exercise, extra insulin, less food, etc.).
This will allow planning ahead to prevent a low
with a similar cause in the future. Preventing
minor lows during the night is very important.
More than half of severe lows occur during
the night. One study in children found that 75
percent of severe lows occur during the night.
The use of Lantus insulin (Chapter 8) and
insulin pumps rather than insulins that peak
during the night (e.g., NPH at dinner or
bedtime), is now helping to reduce the
nighttime lows.

RECOGNIZING A LOW
BLOOD SUGAR
It is important to recognize a low blood
sugar at the earliest possible time. By doing this,
the reaction will not progress to a severe
reaction. The common symptoms are listed
above, but they can vary from person to person.
The early warning signs of a reaction are due to
the release of a hormone called adrenaline.
Most people make it when they are excited or
scared. Another name for this fight or flight
hormone is epinephrine. It causes shakiness,
sweating, dilated pupils, a rapid heart rate and
other symptoms. During the day, it is released
when the blood sugar falls below 70 mg/dl (3.9
mmol/L). People who have had diabetes for a
longer period of time often make less of the
protective hormones with low blood sugar,
particularly at night. Some people tend to have
only mild reactions and can easily detect
symptoms. This seems to be more common in
the first few years after diagnosis. Others may
have more difficulty detecting symptoms. This
seems to happen to people who have had
diabetes longer or whose blood sugars run at
more normal levels. A term, hypoglycemic
Chapter 6 Hypoglycemia (Low Blood Sugar)

37

unawareness is sometimes applied to this

condition, and it is discussed later in this
chapter. Sometimes this is due to less adrenaline
being available. In other cases, the lack of
symptoms may be due to a slow or less dramatic
fall in blood sugar levels, such as from 70 to 50
mg/dl (3.9 to 2.7 mmol/L) rather than from
170 to 50 mg/dl (9.5 to 2.7 mmol/L). Some
people are less likely to detect low blood sugar
in the morning because the sugar has fallen
gradually during the night. Thus, adrenaline
release and its symptoms did not occur.
Symptoms are more likely to occur with a
greater and faster fall of a blood sugar level.
Different children learn to tell if they have
low blood sugar at different ages (see Chapter
18). It may be possible to train young children
(or older people who have difficulty detecting
low blood sugars) to recognize certain signs.
Parents may frequently need to remind a
young child
Remember how you felt shaky (or
whatever the feeling was [one toddler
would say, Theres a tiger in my
tummy.]) and you came and told me?
You did a good job! Remember to tell a
grown up if you feel that way again.
Ask the child how they feel when a low is
found. This will reinforce their awareness of
the symptoms. For very young children, the
parent can often tell when the child has low
blood sugar by the type of cry or fussiness
he/she presents. Young children may be
unaware of lows because they are busy playing.
It is critical for adults to be aware of the need
for snacks. A snack is especially important when
a child discontinues naps during the day. It can
be compared with an adult adding a new
exercise program.

PREVENTING INSULIN
REACTIONS (THINKING
AHEAD)
It is important to prevent lows. This may
allow the stores of epinephrine and glucagon

38

Chapter 6 Hypoglycemia (Low Blood Sugar)

(and other protective hormones) to build up

so they are available when needed.
Considerations in preventing insulin
reactions:
Snacks can be important when:
heavy physical exercise or all day exercise is
planned: hiking, skiing, etc.
the bedtime blood sugar is below 130
mg/dl (7.3 mmol/L).
a person has a low (but be careful not to eat
in excess).
Insulin:
Reduce the dose of insulin which will be
acting during the exercise period.
Take the insulin injection AFTER a hot
shower, bath or hot tub.
For some people, with careful insulin dose
adjustments, or using Lantus insulin or an
insulin pump, extra snacks may not be
needed (unless < 130 mg/dl [< 7.3
mmol/L] at bedtime).
If doing corrections for high blood sugars at
bedtime or during the night, use half the
usual dose.
Blood sugar:
Doing extra blood tests before, during and
after periods of exercise will help to prevent
lows and plan for future activity.
Knowing a blood sugar level can help decide
the amount of treatment needed.
Do a blood sugar test during the night if it
was a heavy exercise day.
Always do a recheck if the value was low
prior to the bedtime snack (to be certain it
came back up).

False Reaction (False-Low)

A rapid fall in blood sugar can also cause
an adrenaline release and symptoms even if a
low blood sugar does NOT occur. We call this
a false reaction. The symptoms of low blood

sugar occur, but the blood sugar is not low. A

common example is when children eat lunch at
school. Their blood sugar rises to a value of
perhaps 250 mg/dl (13.9 mmol/L) after
eating. They then go outside to play and the
sugar might fall to 150 mg/dl (8.3 mmol/L)
fairly rapidly. Adrenaline is released and the
symptoms of having a reaction occur. Yet their
blood sugar is 150 mg/dl (8.3 mmol/L) and
they DO NOT HAVE LOW BLOOD
SUGAR. It was just the rapid fall in blood
sugar that caused an adrenaline release and
made them feel like they were having a
reaction. Since the sugar is not truly low, they
do NOT need to drink sugar pop (soda) or
juice, which will only raise their blood sugar.
They might feel better if they ate some solid
food, such as crackers or fresh fruit. It is
important to remember that THE ONLY
WAY TO TELL IF SOMEONE HAD A
RAPID FALL IN BLOOD SUGAR OR A
TRULY LOW BLOOD SUGAR IS BY
DOING A BLOOD SUGAR TEST.
Whenever possible, a blood sugar test should
be done when the symptoms of low blood
sugar occur.

TREATMENT FOR
A LOW BLOOD SUGAR
(INSULIN REACTION
see Tables 1 and 2)
The general rule is to GIVE SUGAR IN
SOME FORM AS FAST AS POSSIBLE. If the
reaction is not severe, do a blood sugar test
first. If you are not able to do a blood sugar,
then just give milk, juice or sugar pop. A
person with diabetes wont get sick from excess
sugar. It will just cause high blood sugar and
then be passed in the urine. Insulin reactions
come quickly and should be treated at once by
the person, parent, friend or teacher.
Different forms of sugar can be carried with
them to treat low blood sugar. PEOPLE
WITH DIABETES SHOULD CARRY
SUGAR PACKETS OR GLUCOSE TABLETS
IN THEIR POCKETS AT ALL TIMES FOR

EMERGENCIES. Candy is too tempting. It

also may be taken by other children. A special
pocket for sugar packets can be sewn inside of
gym shorts. Some people carry them in a
jogger wallet attached to a shoe. Others slip
packets in high stockings. It is often best to
wrap the packet in foil or a plastic bag in case of
leaks. Insta-Glucose comes in a tube and
looks like toothpaste. It is available in most
pharmacies. A tube of clear cake gel or honey
tube from the grocery store will also work.
After the blood sugar is back up, the person
may want to eat some other longer-lasting solid
food, like crackers or 1/2 a sandwich. The
liquid sugar will be absorbed more quickly if the
person waits before eating the solid food.
Gradually, each person will become familiar
with the type of reactions that occur. The
person will learn how severe the reactions tend
to be, when they are most likely to occur and
how best to treat them.
Eventually, as a person becomes more
familiar with diabetes, it may be possible to
treat the various reactions differently.
Remember, when possible, it is always wise to
do a blood sugar if the reaction is not severe. If
the level is above 60 mg/dl (3.3 mmol/L), it
may be possible to treat the reaction with fresh
fruit and solid food rather than milk, juice or
sugar pop. ALSO, REMEMBER THAT IT
TAKES 10 TO 20 MINUTES FOR THE
BLOOD SUGAR LEVEL TO RISE, AND
IT IS WISE TO WAIT UNTIL THE
VALUE IS BACK UP TO RETURN TO
NORMAL ACTIVITY. IT IS
IMPORTANT TO TEST THE BLOOD
SUGAR AFTER THE LOW BLOOD
SUGAR TO MAKE SURE IT HAS
RETURNED TO NORMAL. SOME
PEOPLE USE THE RULE OF 15,
TAKE 15g OF CARBOHYDRATE AND
TEST AGAIN IN 15 MINUTES. (THEN
IF THE BLOOD SUGAR IS STILL
BELOW 70 mg/dl [3.9 mmol/L], HAVE
ANOTHER 15g OF CARBOHYDRATE.)
Some sources of quick-acting sugar with
appropriate amounts for people of different
ages are given in Table 1.
Chapter 6 Hypoglycemia (Low Blood Sugar)

39

Table 1

Sources of Quick-Acting Sugar (Glucose) for Hypoglycemia

FOOD
(Measured in grams
of carbohydrae)

5 years or less
(10g)

AGE
6-10 years
(10-15g)

over 10 years
(15-20g)

Glucose Tabs
(4g each - check label;
some = 5g)

3-4

4-5

1/3 tube

1/3-1/2 tube

1/2-2/3 tube

1 tube

1 tube

1-2 tubes

Apple juice
(1/2 cup = 15g)

1/3 cup

1/3-1/2 cup

1/2-2/3 cup

Orange juice
(1/2 cup = 15g)

1/4-1/2 cup

1/2-3/4 cup

3/4-1 cup

Sugar
(1 tsp = 4g)

2 tsp

3-4 tsp

4-5 tsp

Honey
(1 tsp = 5g;
do not use if child is
less than two years old)

2 tsp

2-3 tsp

3-4 tsp

Regular pop (soda)

(1 oz = 3g)

3 oz

4-5 oz

5-6 oz

3/4 cup

1 cup

1 1/2 cup

4-6

6-8

Skittles
(1g each)

10 pieces

10-15 pieces

15-20 pieces

Sweet Tarts
(1.7g each)

6 pieces

6-8 pieces

8-12 pieces

Raisins
(1 Tbsp = 7 1/2g)

1-2 Tbsp

2 Tbsp

2 1/2 Tbsp

Instant Glucose
(1 tube = 31g)
Cake gel
(1 small tube = 12g)

Milk
(12g/cup)
LIFE-SAVERS
(2.5g each)

g = gram; tsp = teaspoon; Tbsp = Tablespoon

40

Chapter 6 Hypoglycemia (Low Blood Sugar)

TREATMENT BY
SEVERITY OF REACTION
(see summary, Table 2):
Mild Reaction (such as hunger at an
unusual time, pale face, shakiness or
irritability): If possible, do a blood sugar
test. If below 60 mg/dl (3.3 mmol/L),
give a glass of milk, a small glass (4 oz) of
juice or sugar pop (soda). Wait 10-15
minutes for absorption of the liquid sugar
and then give solid food (crackers,
sandwich, fresh fruit, etc.). If the blood
sugar is above 60 mg/dl (3.3 mmol/L),
give just solid food.
Moderate Reaction (very confused or
spacey, very pale or very shaky): Give InstaGlucose, Reactose, Monojel or any
source of simple sugar, such as sugar pop or
juice. One-half tube of the Insta-Glucose
can be placed between the cheeks and gums,
and the person should be told to swallow.
Do a blood sugar test as soon as it is
possible. Always check for the risk of
choking. Repeat the blood test after 10-15
minutes to make sure it is above 60 mg/dl
(3.3 mmol/L). If not, repeat the initial
treatment and wait another 10-15 minutes.
Once the blood sugar has risen above 60
mg/dl (3.3 mmol/L) give solid food.
Severe Reaction: If the person is
completely unconscious, it is risky to put the
concentrated sugar around the gums. It
could get into the airway. It is better to just
give glucagon as instructed in Table 3 in this
chapter. Remember to do the blood sugar
level as soon as possible. If the person does
not improve after 10-20 minutes, it may be
necessary to call 911 to get extra help. A
second dose (same amount) of glucagon
(from the same vial) can also be given. In
the preliminary part of the Diabetes Control
and Complications Trial (DCCT; Chapter
14), one of every 10 people (10 percent)
receiving standard treatment had a severe
reaction each year. One of four people (25
percent) on intensive treatment (including

insulin pumps) had a severe insulin reaction

each year. Every family must have glucagon
available and know how to use it (see Table
3). Our current hypoglycemia video may be
helpful in understanding how to use
glucagon. Adjustments in the next insulin
dose may be necessary. Call your diabetes
care provider if you need help making this
adjustment.
We are concerned about any blood sugar
below 60 mg/dl (3.3 mmol/L). When
these are obtained frequently in routine
testing, the insulin dose or snacks should be
changed so that further low values do not
occur. In a child under five years old, we are
concerned about values below 70 mg/dl
(3.9 mmol/L). When values are below these
levels at the time of an insulin injection, we
usually recommend not giving the usual
amount of Humalog or NovoLog insulin (at
least until after eating). If two or three values
below 60 mg/dl (3.3 mmol/L) are present
at the same time of day in the same week, a
decrease in insulin dose is probably needed.
CALL THE DIABETES CARE
PROVIDER IF HELP IS NEEDED.
Hypoglycemic Unawareness: Sometimes
low blood sugars will be found during
routine testing, and the person will not have
had symptoms. This may be due to a very
gradual fall in the blood sugar, or in young
children, because they have not learned to
recognize the symptoms. Some adults with
very strict sugar control do not release
adrenaline and may have the problem
medically referred to as
HYPOGLYCEMIC UNAWARENESS.
In this case, they must not aim for such
strict blood sugar control. Sometimes the
insulin dose can be lowered. After blood
sugars have been higher for two or three
weeks, it may be possible to again recognize
low blood sugars.
One-sided Weakness (paralysis): It is not
known why, but on rare occasions some
people experience weakness (or paralysis) on
one side of the body with a severe insulin
Chapter 6 Hypoglycemia (Low Blood Sugar)

41

Table 2

Hypoglycemia: Treatment of Low Blood Sugar (B.S.)

Always check blood sugar level!
Low Blood Sugar
Category
MILD

MODERATE

SEVERE

Alertness

NOT ALERT

UNRESPONSIVE

Unable to drink
safely (choking risk)
Needs help from
another person

Loss of consciousness

ALERT

Seizure
Needs constant adult help (position
of safety)
Give nothing by mouth (extreme
choking risk)

Symptoms

Mood Changes
Shaky, Sweaty
Hungry
Fatigue, Weak
Pale

Lack of Focus
Headache
Confused
Disoriented
Out of Control
(bite, kick)
Cant Self-treat

Loss of Consciousness
Seizure

Actions to take

Check B.S.
Give 2-8 oz
sugary fluid
(amount age
dependent)
Recheck B.S. in
10-15 min.
B.S. < 70,
repeat sugary
fluid and
recheck in 1020 min.
B.S. > 70, (give
a solid snack)

Place in position of
safety
Check B.S.
If on insulin pump,
may disconnect or
suspend until fully
recovered from low
blood sugar (awake
and alert)
Give Insta-Glucose
or cake decorating
gel - put between
gums and cheek and
rub in.
Look for person to
wake up
Recheck B.S. in 1020 min.
Once alert follow
actions under
Mild column
(Can use low dose
glucagon: [1 unit per
year of age], if very
disoriented or out of
control)

Place in position of safety

Check B.S.
If on insulin pump, disconnect or
suspend until fully recovered from
low blood sugar (awake and alert)
Glucagon: can be given with an
insulin syringe like insulin
Below 5 years : 30 units
5-16 years: 50 units
Over 16 years: 100 units (all of
dose)
If giving 50 or 100 unit doses, may
use syringe in box & inject through
clothing.
Check B.S. every 10-15 min. until
> 80
If no response, may need to

Recovery time

42

10-20 minutes

20-45 minutes

Chapter 6 Hypoglycemia (Low Blood Sugar)

call 911
Check B.S. every hour x 4-5 hours
High risk for more lows x 24 hours
(need to food intake
and insulin doses)

Call RN / MD
and report the episode
Effects can last 2-12 hours

reaction. This can last for one to 12 hours,

but eventually clears. It is particularly
worrisome to doctors in emergency rooms.
They often insist on a very expensive
evaluation to prove that a stroke has not
occurred.

3. Education is also a big factor. Families

can think-ahead and reduce the insulin
acting during the night if there has been
unusual exercise that day. Parents will
often get up at night and do a blood
sugar on those nights.

Preventing Severe Lows: A parents

greatest fear is a severe hypoglycemic
reaction. This is often the biggest factor in
not achieving good sugar control (a low
HbA1c level, Chapter 14). Unfortunately,
the most common time for severe lows to
occur is during the sleeping hours. This is
because the adrenaline response to
hypoglycemia is lower when sleeping and
the person is not awakened when the blood
sugar falls. The good news is that the
incidence of nighttime severe lows is now
decreasing. This is due to:

4. Eventually there will be continuous

glucose monitors that read accurately at
low glucose levels and give alarms to
alert families. The current monitors (see
Chapter 7) give approximately one false
alarm for every true low. This will
improve and will someday allow us to
prevent most severe lows. In the
meantime, we have to do the best we
can with the measures outlined above.

1. Probably the main reason for the

decrease is the recent use of basal/bolus
insulin therapy using insulin analogs.
Most important is the flat Lantus basal
insulin, contrasting with the large peaks
of NPH or Lente insulins working
during the night in past years. The
rapid-acting analogs (H, NL, AP) also
act during the post meal-time rises in
blood sugar, rather than after the rise in
blood sugar has already occurred (as
occurs with human Regular insulin).
This has decreased late-evening lows.
The basal insulin from insulin-pump
therapy also avoids the peaks during the
night and helps to prevent lows.
2. The widespread use of home glucose
monitoring has helped to reduce the
severe nighttime lows. It has been
shown that the risk is greater when the
pre-bedtime glucose level is below 130
mg/dl (7.3 mmol/L). Extra snacks
when the level is low obviously help if
the value is really low at bedtime. It is
important to do a repeat check later to
make sure the blood sugar level has
come back up ( 10 percent of blood
sugars dont come back up).

GLUCAGON
Glucagon is a hormone made in the
pancreas, like insulin. However, it has the
opposite effect of insulin and raises the blood
sugar level. It is rarely needed, but we ask
families to keep it on hand. The expiration date
on the box should be checked regularly and, if
outdated, a new bottle should be obtained. If a
very severe reaction occurs and the person loses
consciousness, glucagon should be given
promptly. It can be stored at room temperature.
It should not reach a temperature above 90 or
below freezing. It can be taken in a cooler with
the insulin and blood sugar strips for trips away
from home.

Use of Glucagon
1. Severe Low Blood Sugar
Glucagon comes in a bottle containing 1
mg as a tablet or powder. There is a syringe
containing diluting solution in the emergency
kit. The method for giving glucagon is shown
in Table 3. This table may be copied and
attached to the glucagon kit.
Sometimes vomiting will occur after a severe
reaction. This may be from the persons own
glucagon output or from the glucagon that was
injected. It usually does not last very long, and
if the blood sugar is above 150 mg/dl (8.3
Chapter 6 Hypoglycemia (Low Blood Sugar)

43

Table 3

Glucagon Injections When To and How To

Use when a person is unconscious or having a seizure.
Keep in a convenient and known place. Store in a refrigerator during
hot weather. Protect from freezing.
Keep a 3cc syringe available or use the fluid-filled syringe in the
emergency kit. An insulin syringe and needle can also be used
(preferably a 1.0cc syringe). Some people tape the syringe to the kit so
they have this readily available (see video on hypoglycemia).
If you have the emergency kit, the fluid does not need to be withdrawn
from bottle 1 (diagram at right) as it is already in the syringe. Put the liquid
into the glucagon vial and swirl gently to mix. The large syringe that the
liquid was in can also be used to give the glucagon injection. Draw up the
dose indicated below. Clear the air pointing the needle upward.

1.
Insert
1/2cc of
air into
fluid
bottle
(1cc
wont fit).
Rotate to
mix.

Withdraw from the mixed glucagon bottle:

If using an insulin syringe, put needle into center of stopper.
(Estimate dose if using the emergency kit syringe.)

0.3cc (30 units) for a child less than six years old
0.5cc (50 units) for a child 6-18 years of age
1.0cc (100 units) for an adult over 18 years of age
If using the syringe that comes in the emergency kit, inject into deep
muscle (in front of leg or upper, outer arm) though it is OK to inject
into the subcutaneous fat. Inject through clothing if needed. If the
glucagon is drawn into an insulin syringe then give it just as you
would an insulin shot. If a blood sugar has not yet been done, it can
be done now.

2.
Draw out
1cc of
fluid from
bottle.

Wait 10 minutes. Check blood sugar. If still unconscious and blood

sugar is still below 60 mg/dl (3.3 mmol/L), inject second dose of
glucagon (same amount as first dose).
If there is no response to the glucagon, or if there is any difficulty
breathing, call paramedics (or 911).
As soon as he/she awakens, give sips of juice, sugar pop or sugar in water
initially. Honey may help to raise the blood sugar for children over the
age of 1 year. After 10 minutes, encourage solid food (crackers and
peanut butter or cheese, sandwich, etc.).
Notify diabetes care team of severe reaction prior to next insulin
injection (so dose can be changed if needed). Complete recovery may
take 1-6 hours.
Please copy this page as often as you wish. Tape a copy to the box of glucagon.

44

Chapter 6 Hypoglycemia (Low Blood Sugar)

3.
Inject the
1cc of
fluid into
bottle
with
tablet.
Mix.

mmol/L), it is not a big problem. If the person

is lying down, the head should be turned to the
side to avoid choking. Urine or blood ketones
should be checked (see Chapter 5) as they can
sometimes also form. If the family is concerned
about the ketones, if the blood sugar did not
rise, or if the vomiting continues, the diabetes
care provider should be called.
2. Low Blood Sugar and Vomiting
Sometimes the blood sugar can be low
(< 60 mg/dl [< 3.3 mmol/L]) and the person
cannot keep any food down. Glucagon can be
mixed (Table 3) and given just like insulin
using an insulin syringe. The dose is one unit
per year of age up to age 15 years. Older
people can just use the 15 units.
For example: a five-year-old would get five
units or a 10-year-old would get 10 units.
If the blood sugar is not higher in 20-30
minutes, the same dose can be repeated. This
treatment has saved many ER visits.

DELAYED HYPOGLYCEMIA
Delayed hypoglycemia is also discussed in
Chapter 13 on exercise. It usually occurs from
4-12 hours after exercise, however it can occur
up to 24 hours after the exercise. For some
people, blood sugars can be high after exercise.
This is due to the normal response of releasing
adrenaline during exercise (or from the extra
snacks). Adrenaline causes sugar to come out
of the liver and raise the blood sugar. At some
point after the exercise, the adrenaline levels go
back down (sometimes not until the time of
sleep), and the sugar moves back into the
muscle and liver. The result can be a low blood
sugar or delayed hypoglycemia.
Prevention involves lowering the insulin dose.
This must be done after heavy exercise even
though the blood sugar may be high. Taking
extra carbohydrate at bedtime (even with high
blood sugar) may also be helpful. Exercise is
essential for the heart and cardiovascular system.
Therefore, it is important to always be thinking
about how to best prevent post-exercise lows.

RECORD ALL INSULIN

REACTIONS
Record insulin reactions in your record
book. Many families circle all values < 60
mg/dl (< 3.3 mmol/L). Try to identify and
record the cause of any low or high blood
sugars (Table 4). If more than two mild insulin
reactions occur in a short time period, call the
diabetes care provider to adjust the amount of
insulin. It is usually possible to call during
office hours, but if a severe reaction occurs, call
the care provider prior to giving the next
regularly scheduled insulin shot.

MEDICAL
IDENTIFICATION
In case of a severe insulin reaction,
EVERYONE needs to know about the diabetes.
This includes teachers, strangers, police, coworkers, friends and medical personnel. The
person with diabetes should wear a bracelet or
necklace with this information. A card in the
wallet is not good enough; this may not be
found by paramedics. A diabetes ID card can
also be stapled to the registration of the car in
the glove compartment. Bracelets or necklaces
can be found at most pharmacies or medical
supply houses.
The MedicAlert Foundation
(provides MedicAlert tags)
2323 Colorado Avenue
Turlock, California 95382
888-633-4298
www.medicalert.org
The MedicAlert tag includes a number that
can be called 24 hours a day for information
concerning both the person and the doctor. The
minimum charge for the bracelet or necklace and
keeping the information readily available 24
hours per day is $35. Then the annual
membership renewal after the first year is $20.
A bracelet, necklace or medallion with your
personal medical information (name, condition
and medications) can be engraved and ordered
through American Medical Identifications, Inc.
Chapter 6 Hypoglycemia (Low Blood Sugar)

45

The prices for an identification tag start at

$21.95.
American Medical Identifications, Inc.
P.O. Box 925617
Houston, Texas 77292
800-363-5985
www.americanmedical-id.com
Colorful sports bracelets are sometimes
preferred and can be ordered from FIFTY 50
PHARMACY. The cost per bracelet ranges
from $9.95 to $14.95 plus $4.50 for shipping.
Mail your order with payment to:
FIFTY 50
1420 Valwood Parkway, Suite 120
Carrollton, Texas 75006
Phone: 800-746-7505
www.fifty50.com
Medical charms are also popular. These
work well for attaching to the toddler shoe
laces. The addresses are:
Miss Brookes Company
P.O. Box 558
Bryant, Arkansas 72089
Phone: 888-417-7591
www.missbrooke.com

Table 4

Some Factors That

Change the Blood Sugar
Lowers:
Insulin
Hot bath, showers or hot tubs may
increase insulin absorption and cause a
low blood sugar
Exercise, although for some people, the
values may be higher immediately
following exercise
Less food or eating late

Raises:
Sugar intake
Glucagon
Hormones such as glucagon, adrenaline,
growth hormone and cortisol
(prednisone); their action is opposite to
that of insulin
Illness (which may cause ketones)
Rapid growth; teenagers usually require
more insulin with increased growth
Menstrual periods (may cause ketones)

For those who desire additional choices, see

www.tah-handcrafted-jewelry.com.
For people who will not wear a necklace or
bracelet, a watch or shoe tag may be the next
best choice. There are medallions that stick to
the front of a wallet, cell phone, insulin pump,
etc. These can be purchased from LIFETAG,
Inc., 888-LIFETAG or www.lifetag.com or
lifetag2@att.net.
Toddlers should not wear a neck chain (too
risky), but they often do well with ankle
bracelets, charms or a medallion laced in the
shoe. The sports bracelet described above
works quite well around the ankle.

46

Chapter 6 Hypoglycemia (Low Blood Sugar)

Emotions such as anger and excitement;

some younger children can have lower
blood sugars with extra excitement
Inhalers given for asthma which have
epinephrine derivatives in them

DEFINITIONS

QUESTIONS AND ANSWERS

Adrenaline (used collectively to include

epinephrine and non-epinephrine): The
excitatory hormone. This is released with a low
blood sugar or a rapid fall in blood sugar, which
then causes the symptoms of low blood sugar
(shaking, sweating and pounding heart).

FROM NEWSNOTES

Glucagon: A hormone also made in the

pancreas (like insulin) that causes the blood
sugar to rise. It is available to inject into people
when they have severe (unconscious) insulin
reactions.

The current statistic (from three

studies) is that four percent to 13 percent of
standard insulin-treated patients have one or
more severe episodes of hypoglycemia each
year. With intensive insulin therapy in the
DCCT, 25 percent (one in four) of subjects had
a severe reaction each year. Glucagon should
be given anytime there is loss of consciousness
without being able to arouse the person. If
paramedics are to be called, it is still wise to give
the glucagon before they arrive.

Hypoglycemia: The term used for a low blood

sugar (insulin reaction).
Hypoglycemic unawareness: The term used
to describe low blood sugars without the person
having any warning signs or symptoms.
Insta-Glucose, Monojel, or Reactose: Source
of concentrated sugar that can be purchased. It
can be given to a person in case of low blood
sugar.
Ketoacidosis (Acidosis): What happens in the
body when not enough insulin is available.
Blood sugar is usually high at this time.
Moderate or large ketones (acetone) are present
in the urine. See Chapter 15.
Rebounding (Somogyi reaction or
bouncing): The process of blood sugars falling
to low levels and then rebounding to high
levels. Ketones may sometimes be present
when this occurs.
Seizure (convulsion): Loss of consciousness
with jerking of muscles. This can occur with a
very severe low blood sugar (insulin reaction).

Q
A

Do we still need to keep glucagon?

YES.

The biggest change in giving glucagon is that

two studies have shown it will work just as fast
when given subcutaneously (the same place as
insulin) as when given into muscle. People used
to think it always had to be given into muscle.
The Eli Lilly Company Glucagon
Emergency Kit comes with the diluting solution
already in the syringe ready to be injected into
the bottle with the powdered glucagon for
mixing. The syringe and needle they provide
can then also be used for the subcutaneous or
intra-muscular injection (either is fine).
Some people have rebounding, a high blood
sugar and even ketones after glucagon.
Vomiting can also occur, but these side effects
can be handled.

Since I have changed to three

injections of insulin per day, and my
Hemoglobin A1c has come down, I
dont seem to feel low blood sugar reactions.
Is this common?

Unfortunately, this is not unusual. It

is called hypoglycemic unawareness.
People on intensive insulin therapy
often do not make the counter-regulatory

Chapter 6 Hypoglycemia (Low Blood Sugar)

47

hormones as effectively as they did previously.

Adrenaline (epinephrine) output is sometimes
reduced in people with very tight sugar control.
This is probably the most important hormone,
which normally increases with low blood sugar
and then causes the symptoms (shakiness,
sweatiness, rapid heart beat, etc.). Sometimes it
is possible to reduce the insulin dose to let the
blood sugars run a bit higher for two or three
weeks in order to regain the ability to feel low
blood sugars.
Other hormones which normally help to
raise the blood sugar may also have reduced
output following intensive insulin
therapy. Production of the
hormone glucagon, made in the
pancreas like insulin (normally), is
reduced in most people who have
had diabetes for longer than one
year. Therefore, it also may not be
available to help raise the blood
sugar. It is important to let your
diabetes care provider know if you
are having low blood sugars
without symptoms.

The hot bath or shower (or hot tub)

increases the blood flow to the skin.
As more blood flows to this area, more
insulin is rapidly taken up by the blood
(probably primarily Humalog, NovoLog,
Apidra or Regular insulins). This can then
result in a severe low blood sugar. The answer
is to always take the insulin after the hot
shower or bath. The shower or bath should
not be taken in the 30-90 minutes after
Humalog/NovoLog/Apidra or in the four
hours after taking Regular insulin. This may
help to prevent a severe low blood sugar.

We were recently told at

a clinic visit that our
child should not be
given insulin just prior to a hot
bath, shower or hot tub. Would
you please explain the reason for
this?

Wait to take your shot

after a bath or shower.

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Chapter 6 Hypoglycemia (Low Blood Sugar)