Hypoglycaemia in children — Rapid

Synopsis

Restore glucose rapidly without aspiration or neurological delay, then distinguish insulin-related episodes from fasting intolerance, endocrine deficiency, sepsis, toxic exposure and metabolic disease using a correctly timed critical sample and prevention plan.

In a child with diabetes, treat glucose below 4.0 mmol/L promptly; in any symptomatic or unwell child, confirm with laboratory plasma glucose when possible but never delay rescue treatment.
Autonomic symptoms include pallor, sweating, tremor, hunger, palpitations and anxiety; neuroglycopenia causes irritability, confusion, visual change, seizure, coma or focal neurological signs.
Check glucose early in seizure, reduced consciousness, sepsis, poisoning, prolonged fasting, vomiting, unexplained behaviour change and every seriously ill infant.
If conscious and swallowing safely, give the personal rapid-acting carbohydrate dose, commonly 10 to 20 g in diabetes care, and recheck after 10 to 15 minutes; repeat when still low.
If oral treatment is unsafe, call emergency help and use intravenous or intraosseous 10% glucose under the paediatric resuscitation pathway, or glucagon when rapid vascular access is unavailable and glycogen is likely adequate.
A severe or unexplained episode needs a critical sample during hypoglycaemia if this can be obtained without delaying glucose: laboratory glucose, ketones, insulin, C-peptide, free fatty acids, cortisol, growth hormone, lactate and targeted metabolic tests.
Ketones help organise the differential. Low ketones during hypoglycaemia suggests hyperinsulinism or impaired fatty-acid oxidation; high ketones fit fasting, glycogen or counter-regulatory causes.
After initial correction, provide longer-acting carbohydrate or a glucose infusion, treat the cause and monitor for recurrence because a bolus is brief.
In type 1 diabetes, review insulin timing, carbohydrate, exercise, alcohol in older adolescents, injection sites, CGM alarms and impaired awareness rather than simply reducing every dose.
Recurrent morning episodes, fasting intolerance, hepatomegaly, poor growth, developmental regression, consanguinity or illness-triggered collapse warrants paediatric endocrine or metabolic assessment.

Key red flags

Seizure, coma, focal neurological signs or failure to recover after glucose correction needs emergency and alternative neurological evaluation.

Recurrent hypoglycaemia in infancy or after a short fast suggests hyperinsulinism, endocrine deficiency or metabolic disease.

Low glucose with absent ketones during fasting is metabolically abnormal and requires urgent specialist investigation.

Hypoglycaemia with hepatomegaly, acidosis, hyperammonaemia or raised lactate can represent an inborn error and decompensation.

Possible sulfonylurea, insulin, alcohol or other ingestion requires toxicology, observation and safeguarding assessment.

Poor perfusion, fever or respiratory compromise may indicate sepsis causing the low value rather than an isolated glucose problem.

Frequent nocturnal or severe events in diabetes require urgent regimen and technology review even when average HbA1c appears excellent.

Severe hypoglycaemia

Seizure, unconsciousness or inability to self-treat requires airway protection and parenteral rescue rather than oral carbohydrate.

Investigation priorities

First-line bedside glucoseFirst stepFirst line

Identify a reversible cause immediately in every child with compatible symptoms or serious illness.

Management branches

Conscious childGive fast oral glucose safely

Glucose is below threshold and the child is alert, cooperative and able to swallow.

Give the individual rapid-carbohydrate amount, commonly 10 to 20 g in paediatric diabetes plans, using a reliably absorbed product.
Recheck after 10 to 15 minutes and repeat the dose if glucose remains below 4.0 mmol/L or symptoms persist.
Follow recovery with a meal or longer-acting carbohydrate and identify the insulin, fasting, activity or illness trigger.

Key medicines

Rapid-acting oral glucoseGive the child's individual rescue dose while conscious and swallowing safely, commonly 10 to 20 g in diabetes care; recheck after 10 to 15 minutes and repeat if glucose remains below 4.0 mmol/L.Avoid chocolate or fat-rich food for initial rescue and never give anything orally during seizure, reduced consciousness or unsafe swallowing.

Intravenous or intraosseous glucose 10%For severe hypoglycaemia, give 3 ml/kg of 10% glucose through secure IV or IO access under the paediatric resuscitation pathway, remeasure promptly and begin an appropriate maintenance infusion or feed.Confirm line patency because extravasation injures tissue, avoid overly concentrated peripheral solutions, and anticipate recurrence after the bolus.

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