# Diabetes uk hypo advice



## ruthelliot (Jan 10, 2012)

As Ben is registering for school next week I have been trawling through various handouts etc to take with me as I think it will take a bit of polite encouragement to get the school up to speed. Anyway I found the following advice in a handout for schools from DUK with regards treating a hypo - treat with something sugary. Follow this with longer lasting carb ( examples of both given) . Check blood after 15mins and if still hypo give something sugary again.
Now we have been taught that a longer lasting carb must NOT be given until blood is already above 4 as this can delay absorption of sugary food/drink and allow the hypo to get worse. It was only after we changed hospitals we were told this so I guess opinion must vary though it makes sense to me. Just a bit worrying if even the DUK handouts are not in agreement with what I will be saying!


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## kellymedkelly (Jan 10, 2012)

ruthelliot said:


> As Ben is registering for school next week I have been trawling through various handouts etc to take with me as I think it will take a bit of polite encouragement to get the school up to speed. Anyway I found the following advice in a handout for schools from DUK with regards treating a hypo - treat with something sugary. Follow this with longer lasting carb ( examples of both given) . Check blood after 15mins and if still hypo give something sugary again.
> Now we have been taught that a longer lasting carb must NOT be given until blood is already above 4 as this can delay absorption of sugary food/drink and allow the hypo to get worse. It was only after we changed hospitals we were told this so I guess opinion must vary though it makes sense to me. Just a bit worrying if even the DUK handouts are not in agreement with what I will be saying!



My child has just developed Type 1 and we were told treat a hypo with something sugary and then a long asting carb after is this not the right thing to do?


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## Mark T (Jan 10, 2012)

My local NHS also says no long acting carbs till over 4 mmol/L too - see here http://www.meht.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=2236

In case that link doesn't work, it's found on this page at the top right under "Management of Hypoglycemia".


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## novorapidboi26 (Jan 10, 2012)

very generalized I agree.............

every patient is different though and different methods work for different people, that's what you can say anyway if you encounter any problems.........


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## Tina63 (Jan 10, 2012)

We were told fast acting carbs (coke/dextrose tablets) followed by cereal bar, and only after a month or two and reading on here did I query the timing. We had been giving both together, the coke followed straight after by the cereal bar. 

We were then told as above, just the fast acting first (coke/dextrose), wait 10-15 mins, test again, if over 4 have the cereal bar, if under 4 more coke/dextrose, then test again after a further 10/15 mins, then the slower acting if over 4 then.  So for the first couple of months we were doing it wrong.

My son did have a day at school where he went down to 2.8, and after testing again hadn't come up far enough, so the school nurse told him to have another mini can of coke, so at least she seemed to know what she was doing thank goodness!

I don't know if we misunderstood at the start, as you are bombarded with all this information in the first 48 hours and go into information overload, I will have to go and look at all the sheets we were given and see if they could do with modifying their information sheets for other families.


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## Tina63 (Jan 10, 2012)

Now I've re-read it (a year after first receiving it!) it does say give 10g glucose (150ml coke, lucozade sport, 2-4 glucose tablets or 1 tube glucogel) then wait 10-15 mins before giving 15g slow release carbs, unless you are just about to have a meal.

I remember then worrying though whether to give Novorapid before a meal if you had just treated a hypo.  I believe we were told eat first, then inject the Novorapid, possibly dropping 1 or 2 units off.  It is so complicated at the start.  You really don't know what to do to be right, and as it's your child and not you feeling 'funny', it's so hard to gauge what's the right thing to do.


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## Pumper_Sue (Jan 10, 2012)

ruthelliot said:


> As Ben is registering for school next week I have been trawling through various handouts etc to take with me as I think it will take a bit of polite encouragement to get the school up to speed. Anyway I found the following advice in a handout for schools from DUK with regards treating a hypo - treat with something sugary. Follow this with longer lasting carb ( examples of both given) . Check blood after 15mins and if still hypo give something sugary again.
> Now we have been taught that a longer lasting carb must NOT be given until blood is already above 4 as this can delay absorption of sugary food/drink and allow the hypo to get worse. It was only after we changed hospitals we were told this so I guess opinion must vary though it makes sense to me. Just a bit worrying if even the DUK handouts are not in agreement with what I will be saying!



Hi Ruth,
as Ben is on a pump he should not need any long acting carbs to treat a hypo.
Can you make up a little folder with coloured sleeves Red being hypo treatment page and then write clear instructions as to how YOU want Ben treated.
To much info might be a bad thing to start with and make people feel over whelmed.
Hope Ben enjoys shool and his Mum doesn't spend all day worrying.


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## Adrienne (Jan 10, 2012)

Oh deary me.  Ok this is in capitals as it is very very important :

DO NOT USE ANYTHING BY DUK FOR HYPOS for kids with type 1 at least.

Please always use any paperwork or leaflets or flyer from JDRF only.   They specialise in children and quite frankly they do get the information right.

There is so much wrong with the info that DUK give out.   It is extremely frustrating and CWD are working hard to get the DUK information changed, lots of it.   

Sorry if others do not agree with this but thems the facts.

Ruth, your DSN should have prepared a careplan for Ben for school with you.  If this has not been done, get in touch with her asap and ask her to help you write a care plan.  

If you go onto the cwd website you will find templates for careplans.   If you go onto the cwd email group and ask then you will be offered lots of careplans already in use and tried and tested for kids of all ages in schools.   It is extremely important you have a care plan which is clear and covers everything from PE (I know he is young but the school need to learn from the beginning) and playtime, lunch time, hypos, hypers and what and how and when to do things.

Please please do not use DUK leaflets until they are correct.

The correct hypo rules on a pump (and MDI as well actually) are :

*The 15 rule

If under 4.0 mmol give 15 cho (carbs) of quick acting ie 100 ml lucozade, 150 ml party size can of coke (or Spirte).   You can use x amount of jelly babies but liquid is the quickest thing for a hypo.

Wait 15 minutes and then retest.     

If levels are 4.0 and above do nothing else.

If levels are still under 4.0 mmol then repeat 15 cho of quick acting carbs.



That is the 15 rule.   You do not need any long acting with a pump and the latest (but been around for a while now) rules for MDI as well.    The basal (background) on a pump and also the background insulin on MDI (Levemir or Lantus Glargene) will keep levels ok, that is the theory and if your settings on your pump are correct and working then that theory works just fine.

Hope that helps.

(crawling back in corner due to what I said about DUK, fast ............)*


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## ruthelliot (Jan 10, 2012)

Yip Sue think I'll dispense with leaflets etc and just make up my own sheets. And yeah it is quite rare Ben will need any other carb at a hypo unless he's been very active and then I guess because his basal is so low at times even dropping that wouldn't be enough, but that's unlikely at school I think. 
Will be hard not to worry those first few months - there is only one other child with diabetes at the school just now and she is under a different hospital ( where Ben was initially) and i think they have given the school the impression it's no big deal and no one needs to know much. The other pupil is on mdi and the school aren't injecting so I don't know how keen they will be to admin insulin via a pump. My team were fantastic at educating Bens nursery though and they can now carb count like true pro's and are super aware of his hypos etc -I think to some extent I've been spoiled by how supportive they've been, but hopefully our dsn can work her magic on the school too!My niggling worry is that Ben doesn't always have great hypo awareness and though he is quite independant he'll only be just 5 when he starts so is going to need a watchful eye!  Oh the joys!!


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## ruthelliot (Jan 10, 2012)

Thanks Adrienne - please dont stay in corner too long!!
That's really useful advice thank you I will get onto that. Waiting on dsn to get in touch and appt with school tues.


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## trophywench (Jan 10, 2012)

My understanding was that the longer acting carb was more to help the liver replenish after it's 'dumped' because if it has done, it sucks up the original hypo remedy and you therefore stay hypo - but thinking about it - that's why you treat again with fast-acting until it comes up, isn't it?  

It's probably to do with the old insulins we were on - because the fast acting part wasn't very fast at all really, so the slower carb would have been needed, to match the speed of the already injected older insulin.

Does that make sense?


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## Northerner (Jan 10, 2012)

It makes sense to me TW. Also makes sense that you wait until no longer hypo before having any longer acting carb. One thing that I have always worried about is the waiting of 15 minutes after the first hypo. I have had hypos (rarely, it's true) that I have treated then realised I'm still very much on the slide so treat again within 5 minutes - if I hadn't I suspect I may not have been capable in 15 minutes! I guess it's much different with a child where there are other adults present to observe though, so hopeflly it would be noticed that the child was getting worse, not better. Maybe this ought to be clarified though, as someone just following rules might think they *have* to wait the full 15 mins.


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## margie (Jan 10, 2012)

On the carb counting course I attended they said you should delay the snack until you were above 4. The reason being that the snack could slow down the uptake of the fast acting carbs.


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## Pumper_Sue (Jan 10, 2012)

trophywench said:


> It's probably to do with the old insulins we were on - because the fast acting part wasn't very fast at all really, so the slower carb would have been needed, to match the speed of the already injected older insulin.



Nope TW that thinking can not be right.
I use the old! insulin's and have never ever used the slow acting carbs as a follow up.
As a little one  (4 to 8 yrs) I used 1 sugar cube to treat a hypo and as I became older it went up to two sugar cubes.
As an added bonus a slap was also administered if it was found out I had given my sugar lumps to the horse I had been riding


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## Adrienne (Jan 10, 2012)

Northerner said:


> It makes sense to me TW. Also makes sense that you wait until no longer hypo before having any longer acting carb. One thing that I have always worried about is the waiting of 15 minutes after the first hypo. I have had hypos (rarely, it's true) that I have treated then realised I'm still very much on the slide so treat again within 5 minutes - if I hadn't I suspect I may not have been capable in 15 minutes! I guess it's much different with a child where there are other adults present to observe though, so hopeflly it would be noticed that the child was getting worse, not better. Maybe this ought to be clarified though, as someone just following rules might think they *have* to wait the full 15 mins.



Mmmm not entirely sure I agree with you there Northerner.    

Obviously as adults you all know how to treat yourselves hehehe so I'm not telling any of you to change things as you are 'doing it wrong' at all.  Goodness me know.

I think that newly diagnosed should absolutely follow the 15 rule.  Otherwise they will panic and just keep testing and over treating the hypo and this is where we have lots of rebounds and swings.  You overtreat then you go too high so you correct, and then you drop back down again arghhhh vicious circle and I see so many times with newly diagnosed kiddiwinks as parents panic, quite rightly so mind you.   I still hate hypos but am more relaxed after all this time but am totally aware how serious hypos of any number are.  

The 15 min rule is non negotiable at our hospital (which is one of the leading hospitals for paed diabetic care with a specialist consultant which is unusual in itself).    

However you get to learn don't you what is needed.  I know that a 3.8 ish for Jessica doesn't need full 15 cho generally and that a 2.1 will no doubt need two lots so I give it all at the same time.    

However have you ever experimented Northerner?

I have experimented many times with Jessica and this is what I have found.

I am making these numbers up by the way but it is to show you the general idea.   The timings are all after the initial hypo ie 5 minutes after hypo and then 10 minutes after hypo  :

Hypo :   3.2   (treat with 15 cho immediately)
After 5 mins  :    2.8   (do nothing)
After 10 mins :    3.2   (do nothing)
After 15 mins  :   4.3

I have tried this time after time and generally that is the pattern.   It takes a few minutes for the coke or whatever to kick in and work and in the meantime you are still dropping.

However there is the odd occasion where she does still plummet but that could be because of her little bit of pain in the butt pancreas that has still not given up the ghost and randonmly kicks out flipping insulin arghhhhhhhhh


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## Adrienne (Jan 10, 2012)

Pumper_Sue said:


> As an added bonus a slap was also administered if it was found out I had given my sugar lumps to the horse I had been riding



Hahahahahaha   oh that really has me chuckling out loud Sue.  Hilarious


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## Adrienne (Jan 10, 2012)

margie said:


> On the carb counting course I attended they said you should delay the snack until you were above 4. The reason being that the snack could slow down the uptake of the fast acting carbs.



Absolutely true Margie re the delay, spot on.   

However the giving of a slow acting carb after levels are up is old advice now if you are of MDI or a pump but there are lots and lots of hospitals still giving this advice and you obviously have to do what works for you after all I am not a medical professional and cannot advise you otherwise


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## Adrienne (Jan 10, 2012)

trophywench said:


> My understanding was that the longer acting carb was more to help the liver replenish after it's 'dumped' because if it has done, it sucks up the original hypo remedy and you therefore stay hypo - but thinking about it - that's why you treat again with fast-acting until it comes up, isn't it?
> 
> It's probably to do with the old insulins we were on - because the fast acting part wasn't very fast at all really, so the slower carb would have been needed, to match the speed of the already injected older insulin.
> 
> Does that make sense?



If the liver has dumped or used some stores or indeed if you have used the glucagon injection (or done lots of sports) in reality it can take a full 48 hours for stores to be fully replenished but apparently lots will be replenished within 24 hours.  This is why if glucagon been used you should run levels slightly higher for a period to try to prevent glucagon being needed again as it wouldn't work and you would need IV dextrose.  Scary stuff eh


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## Hanmillmum (Jan 10, 2012)

Adrienne said:


> However have you ever experimented Northerner?
> 
> I have experimented many times with Jessica and this is what I have found.
> 
> ...



I've done this too, tested too early (i.e under the 15 mins) and found the numbers still low or dropping away, only to find a further test at desired time finds her well enough above.
As soon as we went to pumping and off the mixes we were told the 15 min rule with no follow up of slow carbs.
Always worked well.


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## ruthelliot (Jan 10, 2012)

Must admit we used to be very guilty of over treating night time hypos in particular by only waiting between 5 and ten mins to retest. We hardly ever get big rebounds know - I suppose a combination of a new found patience during Hypos and better control with pump. We were led to believe at that time most of the rebounds were inevitable thanks to the liver but I now realise just as many were us overtreating.


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## Adrienne (Jan 10, 2012)

ruthelliot said:


> .......rebounds were inevitable thanks to the liver ......




Hiya

Me again, sorry. 

I just wanted to pick up on that.   DUK sent a message out, which we are disputing extremely strongly, in their Balance magazine, that 'most' hypos will sort themselves out at night so not really necessary to check.

'Most'.   Well what the hell happens to the other people !!!!  This is the problem.

Many people's livers do NOT behave like that when hypo.  Fact.   Many people's bodies have lost that mechanism.   I'm not the best person to explain this, but I can find a lady who can if anyone wants me to.

This rebound stuff entails the pancreas 'talking' to the liver and telling it to kick out to raise levels.

Jessica is different, she has no pancreas so it can't talk to anything so the liver kicks out nothing at all unless glucagon given.  I have no idea what happens with sports though and whether it is a different process.

Many parents, because they test at night, know that this process does not go through.    Studies should that the majority of children do NOT wake up when hypo at night hence the reason many parents test at night, just too damned risky to chance it quite frankly.   Anyway that is a another thread another day.........

So no-one can rely on the liver kicking out to raise levels, unless you are absolutely 100% sure that happens in your body.

Plus if this allegedly works at night, then they the hell do we treat hypos during the day !

I can get a link to ISAP (International guidelines that should be followed) if you like which says about night time hypos and what all teams should be telling their patients (which I know doesn't happen and just does my head in as it is dangerous not to).

Ok ranting over, back in the corner.


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## trophywench (Jan 10, 2012)

LOL at whoever said 'if you know how your hypos/liver will behave'

Nobody knows! - we do get to know that usually this or that happens - but there's absolutely no telling whether it will go like that today.  For things that you do often eg going to the gym or whatever, you observe and note and react accordingly next time.  But no guarantees!


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## justlikethehotels (Jan 10, 2012)

Very interesting ... I've just re-read G's care plan and it says "Give  50ml - 100ml of Lucozade or 3 glucose tablets. If G's response is slow (more than 10 mins) repeat. Once G is back to normal give her a form of carbohydrate to eat ..."

I was sure I'd been told once she was feeling better - and as her only symptoms so far are being tongue tied and shakey that's pretty much instant ...

It's been working OK with the daytime hypos, but the ones at night (thankfully before she's in bed) it's been hard to get her levels up - maybe this is why! 

Thanks for this ... will try not to panic and give her carbs within 10 mins of the fizzy stuff or glucose tablets next time and see if it makes a difference.


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## Adrienne (Jan 10, 2012)

justlikethehotels said:


> Very interesting ... I've just re-read G's care plan and it says "Give  50ml - 100ml of Lucozade or 3 glucose tablets. If G's response is slow (more than 10 mins) repeat. Once G is back to normal give her a form of carbohydrate to eat ..."
> 
> I was sure I'd been told once she was feeling better - and as her only symptoms so far are being tongue tied and shakey that's pretty much instant ...
> 
> ...



Hahaha yes no panicky and giving fizzy stuff too soon

100ml of lucozade is approx 15 carbs (actually I think it is 17 off the top of my head).    I find that for a 3.7 and above less that 100 mls is ok but you just learn this stuff as you go along.

What I posted is a starting point (although really non negotiable rules ) but as you get to know what it takes then great.

Also just a quick tip when you give glucotabs have a glass of water as well, will help them to absorb so much quicker.   We can't use glucotabs for hypos they just don't work and do nothing, amazing but there you go.

Also I wouldn't, whilst caring for a child (especially a young one under 10), go solely on how they feel and what they are doing etc.  Some kids have no symptoms at all and some do at day time and never at night and some it might come as they get older but some never.

Always test (am sure you do) rather than go on symptoms.


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## trophywench (Jan 10, 2012)

17.2g for 100ml Adrienne (and I didn't even need to look, how sad is that ....)


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## Adrienne (Jan 11, 2012)

trophywench said:


> 17.2g for 100ml Adrienne (and I didn't even need to look, how sad is that ....)



Hahaha I think I qualify to join you in that sad group.   I thought it was 17 odd but just pulled that out of my head from somewhere.


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