Severe Hypoglycemia: Is It Still a Threat for Children and Adolescents With Type 1 Diabetes?

Abstract

Severe hypoglycemia is defined as a condition with serious cognitive dysfunction, such as a convulsion and coma, requiring external help from other persons. This condition is still lethal and is reported to be the cause of death in 4-10% in children and adolescents with type 1 diabetes. The incidence of severe hypoglycemia in the pediatric population was previously reported as high as more than 50-100 patient-years; however, there was a decline in the frequency of severe hypoglycemia during the past decades, and relationship with glycemic control became weaker than previously reported. A lot of studies have shown the neurological sequelae with severe hypoglycemia as cognitive dysfunction and abnormalities in brain structure. This serious condition also provides negative psychosocial outcomes and undesirable compensatory behaviors. Various possible factors, such as younger age, recurrent hypoglycemia, nocturnal hypoglycemia, and impaired awareness of hypoglycemia, are possible risk factors for developing severe hypoglycemia. A low HbA_1c level is not a predictable value for severe hypoglycemia. Prevention of severe hypoglycemia remains one of the most critical issues in the management of pediatric patients with type 1 diabetes. Advanced technologies, such as continuous glucose monitoring (CGM), intermittently scanned CGM, and sensor-augmented pump therapy with low-glucose suspend system, potentially minimize the occurrence of severe hypoglycemia without worsening overall glycemic control. Hybrid closed-loop system must be the most promising tool for achieving optimal glycemic control with preventing the occurrence of severe hypoglycemia in pediatric patients with type 1 diabetes.

Keywords: advanced technology; children and adolescents; risk factor; severe hypoglycemia; type 1 diabetes.

Figure 1

Regional brain volume differences associated with hyperglycemia and severe hypoglycemia in youth with type 1 diabetes (15). (A) Regions with smaller gray matter volume in diabetic youth with severe hypoglycemia compared with those in diabetic youth without severe hypoglycemia. (B) Regions of less gray matter, (C) more gray matter, and (D) less white matter associated with greater hyperglycemia exposure.

Figure 2

Predictive low-glucose management system. The MiniMed 640G System (Medtronic, Northridge, CA, USA).

Figure 3

Closed-loop system. The FlorenceD2A closed-loop system (University of Cambridge, Cambridge, UK) (125). Median sensor glucose (A) and insulin delivery (B) during closed-loop insulin delivery period (solid red line and red-shaped area) and sensor-augmented pump period (dashed black line and gray-shaped area) from midnight to midnight. The glucose range 3.9–10.0 mmol/L (70–180 mg/dL) is denoted by horizontal dashed lines (A).