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11. Evidence for Recommendations for Treatment of Hypoglycaemia
11.1 Sublingual administration of sugar in treatment of hypoglycaemia
Sublingual sugar may be used as an immediate irst aid measure in managing hypoglycaemia in children in situations where intravenous administration of glucose
may be impossible or delayed.
Strong recommendation, low quality evidence
his recommendation places value on ease of use, low cost, and high availability in the absence of any serious risk, although the evidence is of low quality.
11.1.1 Evidence and summary of findings
he panel identiied two randomized controlled trials RCTs from Burkina Faso and Mali, cited in a recent review of the management of hypoglycaemia [Achoki, 2010].
Barennes et al 2005 conducted an open-label, quazi-randomized trial of intravenous glucose, sublingual sugar, and oral sugar in Burkina Faso. Children aged
6 months to 15 years presenting to the outpatient department were eligible if: 1 they had symptoms and signs of either acute respiratory infection excluding pneumonia
or malaria; 2 the caregiver agreed to attend an appointment the next morning; and 3 they had a blood glucose level between 3.3 to 5 mmoll.
he study screened 156 children; 87 were excluded, including 19 children initially assigned to the sublingual group, who swallowed the sugar within the irst 10
minutes. Sixty-nine were randomized to one of ive groups: 1 half a tablespoon of water n = 11; 2 IV glucose 8 mL of 30 dextrose administered in a single bolus;
3 oral glucose 2.5 g sugar; 4 single dose sublingual group 2.5 g of wet sugar under the tongue; or 5 double dose sublingual group. he main outcome was treatment
failure: the proportion of children who did not reach blood glucose 5.6 during the study period.
Baseline characteristics were similar across groups. here were no treatment failures in the sublingual or intravenous groups, compared with 8 53 and 9 81.8
in the oral and water groups respectively p 0.05. he approximate bioavailability was 84 for sublingual administration. he mean SD time to reach a blood glucose
5.6 was 28.5 10.6 minutes and 25.7 9.5 for the sublingual and intravenous groups, respectively.
Graz et al 2008 was an open-RCT of intravenous versus sublingual sugar in children with severe malaria and hypoglycaemia in Mali. Children were eligible if
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they had: 1 WHO-deined severe malaria; 2 seizures, or an alteredimpaired state of consciousness; and 3 hypoglycaemia blood gluocose 3.3 mmolL.
Twenty-six children were randomly allocated to receive sublingual sugar a teaspoon [2.5–3.5 g] of moistened sugar; n = 14 or intravenous sugar 5 mlkg
10 glucose; n = 12. Sublingual administration was repeated every 20 minutes for 2 hours. Primary outcome was treatment response rate: reaching a blood glucose
3.3 mmolL during the irst 40 minutes. Secondary outcomes included relapse rate and treatment delay.
he only diference in baseline characteristics was a trend towards more children with coma in the intravenous group p = 0.06. here was no signiicant diference
in the treatment response rate 71 in sublingual and 67 in intravenous, p = 0.81. However, there was a trend towards more relapses in the sublingual group 30
versus 17, p=0.55. Treatment delay was longer for the intravenous group 18.9 minutes versus 5 minutes, and due to this, the increase in blood glucose from time
of diagnosis of hypoglycaemia was faster in the sublingual group.
Complications: two children in the sublingual group swallowed the sugar, and failed to reach normo-glycaemia by 40 minutes. According to study protocol, they
were switched to intravenous delivery. In the intravenous group, the infusion was blocked in one child.
11.1.2 Benefits and risks
Benefits Sublingual sugar appears to be well-tolerated, safe, and eicacious. It is easy to
administer, rapidly increases blood glucose levels, and is better than no treatment in situations where IV glucose infusion may be delayed or not available. It can be
administered by unskilled health-care workers or parents as a irst-aid measure in many rural health centres.
Risks Possibility of treatment failures because of clenched teeth and swallowing of the
sugar. It has 30 hypoglycaemia relapse and could give false conidence in situations where blood glucose levels may not be monitored.
11.1.3 Acceptability and feasibility
Sublingual sugar is child-friendly, easy to administer, and does not require skilled health workers. Children will not be distressed due to inserting an IV line and would
be a more acceptable treatment than IV infusions. Active participation by parents in the care of their children may also increase. As sugar is readily available in most
places, it may be immediately administered in most circumstances and does not require a prescription or other additional materials for use. It is easy to implement
widely in all settings, including peripheral health centres and in the communities where intravenous glucose is not available.
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