Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus: Prevalence and risk factors

doi:10.1016/S0022-3476(97)70121-5

The Journal of Pediatrics

Volume 131, Issue 1, July 1997, Pages 27-33

https://doi.org/10.1016/S0022-3476(97)70121-5 Get rights and content

Abstract

Objectives: To evaluate the prevalence and risk factors of nocturnal hypoglycemia (NH) in children and adolescents with insulin-dependent diabetes mellitus.

Study design: A total of 150 patients, 87% of whom were receiving conventional therapy, were admitted to the hospital for one night. Blood glucose (BG) levels were measured hourly from 10 pm to 8 am .

Results: The prevalence of NH was 47%; NH was asymptomatic in 49% of the cases. Risk factors were as follows: at least two episodes of severe hypoglycemia from onset of insulin-dependent diabetes mellitus ( p = 0.0004), insulin dosage >0.85 IU/kg per day ( p = 0.02), more than 5% of BG measurements ≤3.3 mmol/L during the last month of monitoring ( p = 0.04). The risk decreased significantly with age ( p = 0.0001). Both high predictive values and significant relative risk were found for BG thresholds ≤5.2 mmol/L at dinner time ( p < 0.0001) and ≤6.7 mmol/L at 7 am ( p < 0.0001). When BG values at 10 pm were used, prediction of NH was weak.

Conclusions: Nocturnal hypoglycemia occurred frequently in children and adolescents with insulin-dependent diabetes mellitus. Our study found risk factors that will help pediatricians to identify those children with a high risk of NH. Especially in these patients, counseling based on the BG values before dinner and early in the morning is indicated to reduce the prevalence of NH. (J Pediatr 1997;131:27-33)

Section snippets

Methods

Participation was proposed during 1 year (1994) for all consecutive outpatients with IDDM in our department. Patients not older than 16 years and who had diabetes for more than 1 year were included. No other exclusion criteria were selected. Among 201 eligible patients, 150 (75%) were recruited for the study. Fifteen patients refused to participate and 36 could not be included in this period for various practical reasons. Age, duration of diabetes, and mean of glycosylated hemoglobin values in

Prevalence and Clinical Description of Nocturnal Hypoglycemia

The overall prevalence, defined as number of children and adolescents who experienced at least one hypoglycemic event (≤3.3 mmol/L) divided by the total number of overnights studied, was 47% ( n = 70 patients, 210 episodes). Prevalence of NH was 45% in patients receiving twice daily insulin and 55% in children receiving intensified insulin therapy. Hypoglycemia was asymptomatic in 49% of the children ( n = 34). Symptoms of hypoglycemia, with a glycemic level ≤3.3 mmol/L, were reported by

Discussion

To answer the question whether intensification of insulin therapy is indicated in the whole population of children with IDDM, the evaluation of the current frequency of NH, as well as the research of risk factors, are necessary. Our study shows that in a large sample of 150 unselected children and adolescents, almost half of the children had spontaneous NH. These episodes remained totally asymptomatic in half of the cases, even when an hourly clinical examination was performed. Among the few

Acknowledgements

We thank the patients and their parents for their participation, the nurses who contributed to this research, and the head nurses, Maud Giraud, Francis Laroche, and Annie Meignant for their efficient organization.

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Citation Excerpt :
The risk of nocturnal hypoglycaemia is greatly increased if bedtime blood glucose is below 7.0 mmol/L (126 mg/dL); more than one third develop nocturnal hypoglycaemia if their bedtime blood glucose is below 4.0 mmol/L (72 mg/dL) [8]. Using conventional capillary blood glucose testing (hourly measurements without wakening the child), almost half (47%) had a blood glucose ≤3.3 mmol/L (<60 mg/dL) with half of these events being asymptomatic [9]. When blood glucose was measured at five time-points overnight in children with T1DM, 37.8% had evidence of a blood glucose <3.5 mmol/L (<63 mg/dL) during a single night [10].
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
Dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes
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To determine the association between dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes.
Type 1 adolescents from a randomized trial wore a blinded continuous glucose monitoring (CGM) system at baseline for one week in free-living conditions. Dietary intake was calculated as the average from two 24-h dietary recalls. Non-severe hypoglycemia was defined as having blood glucose < 70 mg/dL for ≥ 10 min but not requiring external assistance, categorized as daytime and nocturnal (11 PM–7AM). Data were analyzed using logistic regression models.
Among 98 participants with 14,277 h of CGM data, 70 had daytime hypoglycemia, 66 had nocturnal hypoglycemia, 55 had both, and 17 had neither. Soluble fiber and protein intake were positively associated with both daytime and nocturnal hypoglycemia. Glycemic index, monounsaturated fat, and polyunsaturated fat were negatively associated with daytime hypoglycemia only. Adjusting for total daily insulin dose per kilogram eliminated all associations.
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Nocturnal hypoglycemia (NH) is common in patients with insulin-treated diabetes. Despite the risk associated with NH, there are only a few methods aiming at the prediction of such events based on intermittent blood glucose monitoring data and none has been validated for clinical use. Here we propose a method of combining several predictors into a new one that will perform at the level of the best involved one, or even outperform all individual candidates.
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On the considered datasets the proposed approach exhibits good performance in terms of sensitivity, specificity and predictive values. Moreover, the resulting predictor automatically performs at the level of the best involved method or even outperforms it.
We propose a strategy for a combination of NH predictors that leads to a method exhibiting a reliable performance and the potential for everyday use by any patient who performs self-monitoring of blood glucose.
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Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus: Prevalence and risk factors☆,☆☆,★

Abstract

Section snippets

Methods

Prevalence and Clinical Description of Nocturnal Hypoglycemia

Discussion

Acknowledgements

J Pediatr

Metabolism

J Pediatr

Am J Med

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

N Engl J Med

Effect of a hypoglycaemic episode on neuropsychological functioning in diabetic children

J Clin Exp Neuropsychol

Cognitive deficits in adolescents who developed diabetes early in life

Pediatrics

Implications of the Diabetes Control and Complications Trial

Diabetes Care

Severe hypoglycemia in IDDM children

Diabetes Care

Induction of hypoglycemia unawareness by asymptomatic nocturnal hypoglycemia

Diabetes