NOCTURNAL HYPOGLYCEMIA IN CHILDREN WITH INSULIN-DEPENDENT DIABETES-MELLITUS

The therapeutic challenge in children with insulin-dependent diabetes mellitus (IDDM) is to obtain satisfactory glycemic control without an unacceptable risk of hypoglycemia. To develop measures aimed at preven ting hypoglycemia in children with IDDM, a good knowledge of the risk and risk factors for this complication is crucial. We conducted a stud y with the following objectives: (1) to evaluate precisely the prevale nce of symptomatic and asymptomatic nocturnal hypoglycemia by performi ng closely spaced blood glucose assays in 150 children and adolescents with IDDM; (2) to evaluate potential risk factors for nocturnal hypog lycemia and the predictive value of blood glucose determinations done daily before the evening meal, at bedtime, and on waking in the mornin g. Nocturnal hypoglycemia was demonstrated in 47% of the study patient s and were asymptomatic in half the cases. The peak time of occurrence was between midnight and 4 h a.m., although two thirds of episodes st arted between 10 h pm and midnight. The main risk factors were (I) a h istory of two or more severe hypoglycemic episodes since the onset of IDDM and a greater than 5% rate of hypoglycemic values among blood glu cose determinations done during the last month; (2) younger age; (3) a n insulin dose greater than 0.85 U/kg/d. Blood glucose levels less tha n 1.20 g/L on waking and less than 1 g/L before the evening meal had h igh positive predictive values (PPV) for nocturnal hypoglycemia (PPV, 62% and RR, 6.3; PPV, 72% and RR, 1.83, respectively). Detection and p revention strategies are suggested. The risk of nocturnal hypoglycemia is inherent in the pharmacokinetic profile of human insulins belongin g to the ''rapidly acting'' category. Appropriate use of the rapid ins ulin analog Lispro, which reduces nonphysiologic hyperinsulinemia, may allow to reduce the frequency of nocturnal hypoglycemia in children w ith IDDM.