Hypoglycemia in infants and children with hyperinsulinism

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Learn about the symptoms and causes of hypoglycemia (low blood sugar) in infants and children with hyperinsulinism, and the importance of treatment.

Key points

  • Low blood sugar (hypoglycemia) is a blood sugar level lower than 3.5 mmol/L.
  • Hyperinsulinism is when the pancreas produces too much insulin.
  • Mild to moderate symptoms of hypoglycemia include shakiness, feeling cold and clammy, mood changes, lack of energy and hunger accompanied by nausea.
  • Advanced symptoms of hypoglycemia include slurred speech, difficulty walking, poor concentration, loss of consciousness and seizures.
  • Prompt treatment of hypoglycemia can help improve symptoms and reduce risk of severe low blood sugars.

What is hyperinsulinism?

Hyperinsulinism (HI) is a condition in which the body produces too much of a hormone called insulin. Insulin is secreted by the pancreas to help prevent high blood sugars. However, in babies with HI, excess insulin is released causing low blood sugars. If HI is not treated, frequent low blood sugars can be dangerous to a baby, which can cause seizures, brain injury or death.

What is hypoglycemia (low blood sugar)?

Hypoglycemia, or low blood sugar, can occur when the blood sugar level drops below the normal range (3.5 – 6 mmol/L). This can be due to illness, decreased food intake, side effects of medications, problems with hormones such as insulin that regulate blood sugar, or unknown causes.

Causes of hypoglycemia

Hypoglycemia is usually caused by one of two things: missed or delayed medication doses or not enough food.

  • Missed or delayed medication being given: Without the medication, your child's body will produce too much insulin.
  • Not enough food: Sometimes your child will get caught up in an activity and forget to eat their snack, sleep through breakfast, or skip a meal.

Mild to moderate symptoms of hypoglycemia (warning signs)

  • Shakiness
  • Feeling cold and clammy
  • Mood changes (suddenly irritable or bad tempered)
  • Lack of energy
  • Hunger, along with nausea due to hunger
  • Restless sleep (crying out, sleepwalking or nightmares)
  • Blurred vision
  • Fast or irregular heartbeat
  • Pale skin
  • Feeling anxious

Treatment of mild to moderate hypoglycemia

Age rangeMild to moderateSevere
1 to 12 monthsOffer breastmilk or formulaCall 911 for an ambulance
*give glucagon if your doctor prescribed it
1 year to less than 5 yearsGive at least 45 mL (1.5 oz) or apple or orange juice
5 to 10 yearsGive at least 90 mL (3 oz) of apple or orange juice
Older than 10 yearsGive at least 120 mL (4 oz) of apple or orange juice
Your child may eat afterwards, but prevent them from eating too quickly as they may choke or vomit

Following treatment check blood sugar 15 minutes later to ensure it is now in the normal range.

Severe symptoms of hypoglycemia

If a mild hypoglycemic episode is not noticed or treated fast enough, the blood sugar level may continue to drop and more severe symptoms may begin to develop. Severe hypoglycemic events are less common and may be more difficult to treat.

Symptoms of a severe hypoglycemic episode include:

  • slurred speech
  • very low energy
  • difficulty walking
  • poor concentration
  • loss of consciousness
  • seizures

Treatment of severe hypoglycemia

Severe hypoglycemia is considered an emergency and your child will need immediate help. If they are unconscious or convulsing, they should not take fast-acting sugar by mouth, including liquids, because they are at risk for choking. Instead, they will need a glucagon injection. Specific instructions will be provided to you by your child’s health care team. Intranasal glucagon is only available for those patients 4 years of age and older.

Glucagon is a hormone that stimulates the liver to release sugar into the bloodstream. It is given by syringe and normally takes about 15 minutes to work. If you are too anxious to administer glucagon to your child, call 911 first and then attempt to follow the steps below:

For children who are experiencing an extreme low blood sugar and who are unable to safely eat or drink:

Glucagon injection

  1. Confirm that the glucagon kit has not expired.
  2. Remove the lid from the glucagon.
  3. Remove the needle cap from the syringe.
  4. Inject the entire water contents of the syringe into the vial of glucagon.
  5. Remove the syringe from the vial.
  6. Swirl the bottle gently until glucagon has dissolved completely. The solution should look clear and look and feel like water. If the solution does not appear clear, do not administer the glucagon! Call 911.
  7. Insert the syringe in the vial and turn the vial upside down to withdraw the fluid. Make sure the needle tip remains in the solution.
    • If the child is older than 5 years old, withdraw all the solution (1 mg).
    • If the child is 5 years old or younger, withdraw half the solution (0.5 mg).
  8. Inject the glucagon the way you have been shown.

Intranasal glucagon

  1. Hold the glucagon device between your fingers and thumb.
  2. Do not press the plunger before you insert it into your child's nose or the single dose in the device will be lost.
  3. Insert the tip gently into your child's nostril until your finger touches the outside of their nose.
  4. Push the plunger all the way in.

After your child receives glucagon, they need to go to the emergency department as glucagon can often cause vomiting. All families of children with HI should have an emergency, usable (not expired) glucagon kit on hand and be comfortable using it.

Important things to consider about hypoglycemic events

  • They can happen quickly.
  • They can occur day or night.
  • Symptoms vary, but each child usually exhibit one or two tell-tale signs you will learn to recognize.
  • Hypoglycemia can be difficult to detect in infants or very young children; good indicators are crying, irritability, pale skin, along with a “floppiness” of the head.

Reducing the risk of low blood sugar (hypoglycemia)

Here are some things you can do to help prevent hypoglycemic episodes.

  • Eat meals and snacks on time. A delay of even 30 minutes can cause hypoglycemia.
  • Ensure their medication to treat hyperinsulinism is given on time.
  • Plan for extra activities with prepared snacks; communicate with teachers and caregivers so you know when extra activities are taking place.
  • If your child has two or more unexplained low blood sugar levels in one week, contact your health-care team.
  • Equip your child with fast-acting sugar at school, and at home, make sure there is always fast-acting sugar nearby. Always have a glucagon kit at home, and make sure it is not expired and you know how to use it.
  • Have your child wear a medical alert identification (such as a bracelet) or, if they are older, carry a wallet card.
Last updated: August 30th 2023