Response to Countdown Article About Nighttime Testing
On page 18 of the Summer 2004 issue of Countdown, JDRF's quarterly magazine, begins an article entitled What's Making it so Tough to Avoid Hypoglycemia. The article, written by Robert S. Dinsmoor, introduces readers to hypoglycemia in its opening paragraph:People who have type 1 diabetes know the signs all too well: anxiety, trembling, heart palpitations, sweating, hunger. Without immediate treatment (usually some form of glucose ingested orally), symptoms quickly become more insidious: difficulty thinking, confusion, behavioral changes, and mood swings. At worst, without glucose, a severe hypoglycemic episode can lead to seizures or loss of consciousness, even death.
Even death. Yes, even death.
Parents of children with diabetes fear hypoglycemia more than anything else about diabetes, according to a poll we ran in December 2003. Our readers rated hypoglycemia and the fear of going low to be the hardest part of diabetes by a wide margin -- more than twice as many who said meal planning was the hardest part (38% to 18%). Dinsmoor too reports that the fear of hypoglycemia is always on people's minds:"We asked parents of children with diabetes what they fear most, and at the top of the list was hypoglycemia. Even if you ask most of the adults I treat, their fear is hypoglycemia," says Robert Sherwin, M.D., C.N.H. Long professor of medicine at Yale University School of Medicine and director of the JDRF Center for the Study of Hypoglycemia at Yale University in New Haven, Connecticut.
The risk of going low is, like diabetes itself, always with you. It's with you at home, when you're at school or work, when you're exercising, and it's with you when you're asleep. When you're awake, you have a chance to detect the early symptoms of low blood sugar and treat with rapid-acting sugar. When you're asleep, you often don't have a chance to respond, as Dinsmoor points out in his article. Dinsmoor writes about the normal counterregulatory responses that protect people who don't have diabetes from experiencing severe hypoglycemia. He also writes about the defects in this counterregulatory response that are common in people with type 1 diabetes, and that these defects lead to hypoglycemia unawareness and a "... 25-fold greater risk for severe hypoglycemia." Clearly, people with diabetes, and parents of children with diabetes, are right to list hypoglycemia as their number one fear.
Parents respond to this fear by, among other things, checking their children's blood sugar during the night. In our most recent poll about nighttime testing, 30% of our readers report checking their children's blood sugar every night. Another 10% check at least three times per week, and another 8% check once or twice a week. Adding it up, about half of our readers check nighttime blood sugars at least every week. Why do we do this? Because we fear hypoglycemia and the threat of death, which was pointed out in the first paragraph of Dinsmoor's article.
So, what am I writing about? On page 22, in a side bar to the main article, we find this:Nighttime hypoglycemia is a common problem among children and adolescents with type 1 diabetes, and at least one study has suggested that autonomic responses to hypoglycemia are blunted during sleep and that may make them less likely to be awakened by hypoglycemia. Yet, while it's important to recognize the problem and try to prevent it, some parents become obsessed with it, according to JoAnn Ahern, A.P.R.N., M.S., C.D.E., coordinator of the Yale Program for Children with Diabetes. "Some parents are up all night, checking their kids' blood sugar, and I don't think that's good for anybody. I think it makes the kids afraid. What they may not realize is that eventually the child's liver will secrete glucose, and they'll wake up."
Ahern's position that nighttime testing isn't good, and that kids will become afraid, is at odds with everything written in Dinsmoor's article, at odds with the facts about the seriousness of hypoglycemia, and at odds with how a large percentage of parents feel. It's also at odds with the science, which shows a significant increase in the risk of severe hypoglycemia for people with hypoglycemic unawareness, which is more common in people with long duration type 1 diabetes, those with a history of previous severe lows, and in anyone on intensive insulin therapy. Given the importance of preventing complications, our kids are more often than not on an intensive insulin regimen, putting them within the category of people at risk for developing hypoglycemic unawareness and, as shown in the DCCT, at higher risk for hypoglycemia simply because of the regimen itself. A recent study, for example, notes:Almost 50% of all episodes of severe hypoglycemia occur at night during sleep. Such episodes can cause convulsions and coma and have been implicated as a precipitating factor in cardiac arrhythmias resulting in sudden death--the "dead-in-bed syndrome."
Nocturnal hypoglycemia: clinical manifestations and therapeutic strategies toward prevention
Endocr Pract. 2003 Nov-Dec;9(6):530-43
To assert that nighttime glucose testing is "obsessive" seems to me to be the words of someone who does not have a child with diabetes, does not live with the fear, and -- more importantly -- at odds with the seriousness of severe hypoglycemia. Parents are always protective of their children, whether they have diabetes or not. Parents of kids with diabetes have the added anxiety of an undetected, extended, low blood sugar during the night that could cause death. Therefore, while our children sleep, about one in three of us have decided to get up every night to check our children's blood sugar. We do this so that our children will not be afraid, so that they -- and we -- can sleep well knowing that our decision to check a blood sugar will reduce the risk of a serious low blood sugar going unnoticed and untreated for hours. And until we can purchase an accurate, reliable, continuous sensor that alarms when a blood sugar is out of range, we will continue to ensure that our children sleep soundly with blood sugars at a level that do not pose a risk for harm -- or death.
-- Jeff Hitchcock
Founder and Editor
Children with Diabetes
For More Information
- What's Making it so Tough to Avoid Hypoglycemia (PDF) is the article in which Jo Ann Ahern's comments appear. See page five, blue circle.
- Jo Ann Ahern's Response
- Yale Response to Countdown Article About Nighttime Testing
- The Dead in Bed Syndrome
- Nocturnal hypoglycemia: clinical manifestations and therapeutic strategies toward prevention
- Yale Department of Pediatric Endocrinology, phone (203) 785-4648
- The Curse of Good Control by JoAnn Ahern, in which she stresses the importance of treating lows immediately, "... otherwise, it may be too late." (How can you treat a low immediately that occurs during the night if you don't check blood sugars during the night?)
June 27, 2004
Updated November 19, 2004
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