HYPOGLYCEMIA IN CHILDREN WITH TYPE 1 DIABETES MELLITUS: Risk Factors, Cognitive Function, and Management

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Iatrogenic hypoglycemia is one of the most disturbing yet preventable complications of type 1 diabetes mellitus in childhood. It comes on suddenly and unpredictably, produces physical discomfort, and may disrupt concentration and interfere with performance in the classroom or the workplace. If left untreated, hypoglycemia can cause seizures, coma, accidents, or death, and may even induce permanent brain damage. Repeated severe episodes can trigger a “fear of hypoglycemia” in both the child and parent.12 The resulting psychologic distress can lead to a worsening of metabolic control as the family changes its diabetes management strategies in an effort to avoid hypoglycemia.40 This article discusses changes in mental efficiency induced by a single episode of mild hypoglycemia, as well as the relationship between recurrent hypoglycemia and intellectual deterioration.

Section snippets

HYPOGLYCEMIA AND PERMANENT COGNITIVE DYSFUNCTION

Children and adolescents with type 1 diabetes mellitus have a greatly increased risk of manifesting cognitive deficits.82 The age at diagnosis seems to be the most important risk factor, with children diagnosed in the first 4 to 6 years of life showing the greatest likelihood of cognitive impairments.81, 84 Young children with an early onset of diabetes show a relatively circumscribed pattern of cognitive deficits, with impairments most pronounced on verbal memory tests105 and on tasks that are

ACUTE HYPOGLYCEMIA AND TRANSIENT REDUCTIONS IN MENTAL EFFICIENCY

Glucose serves as the primary oxidative substrate for normal brain function. The brain does not store or produce sizable quantities of glucose but obtains it from systemic circulation via a process of facilitative diffusion across the blood-brain barrier.66 As a consequence, reductions in circulating blood glucose values below a certain level (i.e., hypoglycemia) will affect neuronal metabolism and initiate a cascade of events that includes the activation of counterregulatory hormone secretion,

IMPLICATIONS OF ACUTE HYPOGLYCEMIA

Because of the risk for transient cognitive dysfunction during hypoglycemia, it must be acknowledged that many children may have trouble focusing attention and responding rapidly in the classroom or in the automobile if their blood glucose levels fall below 65 mg/dL. In fact, this link between hypoglycemia and behavior could explain why children diagnosed with diabetes after the first 5 years of life often perform more poorly than their nondiabetic peers on measures of academic achievement and

HYPOGLYCEMIA UNAWARENESS AND AUTONOMIC FAILURE

Epidemiologic studies consistently show that young age and lower glycosylated hemoglobin levels (often associated with intensive insulin therapy) are the major risk factors for severe hypoglycemia.18, 19, 39 It is probable that the iatrogenic development of hypoglycemia unawareness and autonomic failure are the mediators of these findings.

Despite subjective discomfort, the autonomic symptoms elicited by declining blood glucose levels are of major importance in protecting the diabetic patient

HYPOGLYCEMIA: CLASSIFICATION AND PREVALENCE

How common is hypoglycemia in children with diabetes and what factors are associated with its occurrence? Before answering those questions, one needs a standard definition of “mild,” “moderate,” and “severe” hypoglycemia. Investigators have adopted very different operational definitions that have changed over the past 50 years. Both biochemical and clinical criteria have been used at various times,62, 89 with the classification of specific blood glucose values as “hypoglycemic” based on, among

MANAGEMENT

One of the major goals of therapy for children and adolescents with type 1 diabetes mellitus should be the prevention of recurrent damaging hypoglycemia—a goal that necessitates the prevention of frequent recurrent mild hypoglycemia. The difficulty of achieving this goal while maintaining acceptable glycosylated hemoglobin levels can be enormously frustrating for the health care team, patients, and their families.

Hypoglycemia can be prevented only if one knows that it is occurring. This

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    Address reprint requests to Christopher M. Ryan, PhD, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213, e-mail: [email protected]

    This work was supported in part by National Institutes of Health Grants No. HD29487, DK39629, and RR00084.

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    Copyright © 1999 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.