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Severe hypoglycemia in children with IDDM. A prospective population study, 1992-1994
1Department of Pediatrics, Faculty of Health Sciences, Linköping, Sweden.
Insights
Improved metabolic control in children with type 1 diabetes using multiple insulin injections can lead to a slight increase in non-unconscious severe hypoglycemia, but not unconscious severe hypoglycemia. Near-normal HbA1c levels are achievable without significant risk with proper patient education and support.
Area of Science:
- Pediatric Endocrinology
- Metabolic Disorders
- Diabetes Management
Background:
- Intensive management of type 1 diabetes aims for improved glycemic control.
- Severe hypoglycemia is a potential complication of intensive diabetes therapy.
- The relationship between improved metabolic control and severe hypoglycemia incidence requires further investigation.
Purpose of the Study:
- To determine if improved metabolic control in children with type 1 diabetes is associated with an increased incidence of severe hypoglycemia.
- To quantify the extent of any potential increase in severe hypoglycemia.
Main Methods:
- Prospective registration of severe hypoglycemia in 146 children (1-18 years) with intensively treated type 1 diabetes (1992-1994).
- Analysis of severe hypoglycemia (with unconsciousness [U] and without unconsciousness but requiring assistance [NU]) in relation to HbA1c, insulin dosage, and other factors.
- Multiple regression analysis to identify predictors of hypoglycemia.
Main Results:
- Mean HbA1c improved from 8.1% to 6.9% between 1992 and 1994.
- Incidence of U hypoglycemia remained stable (0.15-0.19 events/patient-year).
- NU hypoglycemia incidence slightly increased (1.01 to 1.26 events/patient-year), associated with lower HbA1c, higher insulin doses, and lower proportion of short-acting insulin.
Conclusions:
- Multiple-dose insulin therapy in children with type 1 diabetes achieving low HbA1c levels is linked to a minor rise in NU hypoglycemia, but not U hypoglycemia.
- Near-physiological HbA1c levels can be attained without a pronounced increase in severe hypoglycemia risk.
- Effective self-control, psychosocial support, and education are crucial for safe intensive diabetes management.
Objective:
Is an increased incidence of severe hypoglycemia an unavoidable effect of improved metabolic control? And, if so, to what extent?
Research Design And Methods:
In 1992-1994, severe hypoglycemia was prospectively registered in our intensively treated IDDM population, 146 children 1-18 years of age with > 90% of the patients on > or = 4 insulin injections per day. The two categories, "severe hypoglycemia with unconsciousness" (U hypoglycemia) and "severe hypoglycemia without unconsciousness but needing the assistance of another person" (NU hypoglycemia), were analyzed in relation to yearly mean HbAlc levels, insulin doses and proportion of short-acting insulin, age at onset, duration of diabetes, age, sex, and weight-to-height ratio.
Results:
Yearly mean HbAlc levels improved from 8.1 +/- 1.6% in 1992 to 6.9 +/- 1.3% in 1994. The yearly incidence of U hypoglycemia was 0.15-0.19 events per patient-year, seen in 10-16% of patients, showing no significant increase from 1992-1994. For NU hypoglycemia, slightly increasing figures from 1.01 to 1.26 events per patient-year, seen in 27-38% of patients yearly, were reported. There was no significant correlation between severe (U or NU) hypoglycemia and HbAlc, but still an association was seen in certain calculations. In multiple regression analysis, U hypoglycemia was not related to any factor, but the square root of the rate of NU hypoglycemia was related to lower HbAlc levels (P = 0.0003), higher insulin doses (IU.kg-1.24 h-1) (P = 0.0024), and a lower proportion of short-acting insulin out of the total daily insulin dose (P = 0.031).
Conclusions:
Multiple-dose insulin therapy with rather low yearly mean HbAlc values causes a slight increase of NU hypoglycemia but no increase of U hypoglycemia in our population of children with IDDM. Near physiological HbAlc levels may be achieved without any pronounced risk of increasing the incidence of severe hypoglycemia when multiple-injection insulin therapy is combined with adequate self-control based on psychosocial support and active education.