Hypoglycemia (Adult and Pediatric)

Hypoglycemia is a glucose you measured below 70 mg/dL (3.9 mmol/L). The ADA sorts it into three levels. Level 1 is 54–69 mg/dL (3.0–3.8 mmol/L). Level 2 is below 54 mg/dL (3.0 mmol/L), where neuroglycopenic symptoms begin. Level 3 is the severe one: altered mental or physical function, and the patient needs another person to recover. That holds at any glucose level.

The brain runs on a steady glucose supply. As glucose falls, counterregulatory hormones kick in and produce the adrenergic symptoms. Now the catch: in long-standing diabetes or after recurrent lows, that response is blunted. The patient loses the warning. That is impaired hypoglycemia awareness. Glucagon raises glucose only by drawing on liver glycogen. No glycogen, no response.

• Glucose-lowering drugs: insulin and insulin secretagogues (sulfonylureas) cause most of these lows. The other major classes are unlikely to cause one.
• Reduced intake: skipped or delayed meals, fasting, exercise, vomiting and illness, including reduced oral intake or interrupted feeds in hospital
• Risk factors: very young or older age, cognitive impairment, chronic kidney disease, multimorbidity, prior level 2 or 3 events, and Roux-en-Y gastric bypass (late hypoglycemia from post-meal insulin)
• Hospital causes: insulin ordering and administration errors, sudden corticosteroid dose reduction, reduced dextrose infusion rate, kidney failure, heart and liver failure, sepsis and malnutrition
• Course: a severe episode makes another one more likely. Recurrence is common while insulin or a secretagogue keeps acting.

Symptoms

• Adrenergic (early): shakiness, irritability, tachycardia, sweating and hunger
• Neuroglycopenic (below 54 mg/dL): confusion, drowsiness, slurred speech, seizure, loss of consciousness or coma
• Impaired awareness: for some patients, confusion is the first sign. Others have no symptoms at all.

Red Flags

• Confusion, altered mental status or unresponsiveness with a low glucose (level 3 if another person must help the patient recover)
• Seizure during or after a low glucose
• Glucose below 54 mg/dL (level 2)
• Unable to swallow safely, vomiting or drooling
• Glucose falling again after treatment, or recurrent lows, on insulin or a sulfonylurea

Measure glucose whenever symptoms or an altered mental status meet a possible glucose-lowering drug. Meter values are the working diagnosis. Confirm with a laboratory glucose when the reading does not match the picture.

• Opioid toxicity: Depressed breathing and altered mental status can come with a low glucose too. Check the glucose, and see Naloxone if an opioid is suspected
• Stroke or focal deficit: A new weakness, facial droop or speech change needs a glucose check. A low value does not rule out stroke.
• Intoxication or postictal state: Confusion after alcohol, drugs or a seizure. Measure the glucose. This diagnosis is made by exclusion.
• Sepsis: In hospital, hypoglycemia is a recognized complication of sepsis, as the 2026 ADA Standards set out. It can mask the infection or come with it.
• Alcohol, malnutrition, starvation or adrenal insufficiency: Low glucose with no insulin or sulfonylurea on board. Glucagon works poorly without glycogen, so plan on dextrose. Thiamine may be indicated per protocol. Do not delay dextrose for a symptomatic low glucose.
• Insulinoma: Hypoglycemia with no glucose-lowering drug. Glucagon can provoke an exaggerated insulin release from an insulinoma. That is why it is contraindicated.

1. Check glucose if your protocol allows a meter. Treat by the reading, the symptoms and the mental status. Do not delay treatment of a symptomatic patient while a reading is pending.
2. Alert and swallowing safely: give 15 g of fast-acting glucose by mouth, as glucose gel or tablets. Avoid food high in fat or protein for initial treatment.
3. Recheck in 15 minutes. If the patient is still alert and the glucose is still below 70 mg/dL, repeat 15 g.
4. Not alert or not swallowing safely: give nothing by mouth. Place in the recovery position with suction ready, and call for ALS for IV or IO dextrose or glucagon.
5. Assist with the patient's own glucagon (nasal or autoinjector) if one is available, then call for help. Do not give insulin to a patient in hypoglycemia.
6. Feed after recovery: once the patient is awake and swallowing, give a meal or snack. Insulin or sulfonylurea effects can cause recurrence.
7. Call ALS early and report each glucose value with its time, the drug and dose, and the response.

Differs from NASEMSO model guideline: NASEMSO uses 25 g of adult oral glucose, and treats at 60 mg/dL or less (NASEMSO v3.0, p. 84). This page keeps the ADA 15 g and 70 mg/dL.

Keep treating until glucose holds above 70 mg/dL.

• Glucose check (Paramedic/RN/CCT): before treatment, then every 15 minutes until stable above 70 mg/dL
• IV or IO access (Paramedic/RN/CCT): IV first; IO if IV fails (IO access, IV insertion)
• Dextrose IV (Paramedic/RN/CCT): 10–25 g IV, given slowly into a large vein. Lead with D10: 100–250 mL (10–25 g). D50 is a lower-preference option, 20–50 mL (10–25 g), because it carries extravasation risk; NASEMSO says EMS systems may carry no more than 25% for adults. Repeat in steps until alert and glucose is above 70 mg/dL. See Dextrose
• Glucagon (Paramedic/RN/CCT): 1 mg IM, subcut or IV for a patient 20 kg or more; 0.5 mg for a patient under 20 kg. Repeat once at 15 minutes if there is no response. IV glucagon only under medical supervision, per label or protocol. Contraindicated in pheochromocytoma, insulinoma and known hypersensitivity. Glucagon needs liver glycogen: if there is no response, give dextrose. See Glucagon
• Pediatric dosing (Paramedic/RN/CCT): dextrose 0.5–1 g/kg IV of 10–25% dextrose, to a maximum of 25 g (the adult field maximum): 5–10 mL/kg of 10%, or 2–4 mL/kg of 25% for children over 8 years; 25% maximum under 8 years. Neonates and infants under 1 month: 10–12.5% dextrose maximum (NASEMSO v3.0, p. 86); neonatal dosing is not covered on this page. Glucagon IM/IN: 0.5 mg for a child under 20 kg or under 5 years, and 1 mg at 20 kg or more or 5 years and older (NASEMSO v3.0, p. 85). The weight and age cut-offs overlap at 4 to 5 years; the kit label uses weight alone (20 kg), and this page follows NASEMSO as written. Nasal dosing by age is under Special Populations. See Weight-Based Dosing
• Oral glucose (alert patients only): 15 g PO as in BLS. See Oral Glucose
• Airway (Paramedic/RN/CCT): the obtunded patient cannot protect the airway. Manage per protocol (intubation) and suction before any oral intake
• Monitoring: glucose every 15 minutes, mental status, airway and breathing

• Glucose monitoring: keep checking every 15 minutes until it holds above 70 mg/dL. Then follow the ADA 2026 Section 16 plan. A nurse-initiated hypoglycemia protocol should cover this.
• Recurrent or prolonged hypoglycemia: run a continuous IV dextrose infusion and titrate it to glucose per protocol. Add oral carbohydrate once the patient can swallow.
• Change the plan: any glucose below 70 mg/dL requires a review of insulin and other glucose-lowering orders in ADA 2026 Section 16.
• Sulfonylurea exposure: Expect prolonged or recurrent hypoglycemia. Some protocols use octreotide as an adjunct. Toxicology or the poison center sets its dose. Consult endocrinology or toxicology per local practice, and observe for as long as they advise.
• Cause and documentation: Record the event, its cause and the treatment. ADA 2026 recommends this for inpatient episodes.
• Disposition: admit or observe any level 3 event, and any patient needing a dextrose infusion or repeated doses

• EMS: Document each glucose value with its time, the route and dose of each treatment, and the response. Transport decisions follow local protocol. Patients who needed IV dextrose or glucagon should be transported and monitored.
• Transport: Recheck glucose at least every 15 minutes while a dose or infusion is working. Keep oral glucose and IV dextrose ready. Plan for vomiting and aspiration.
• ED handoff: The handoff needs the glucose values and times. Add the drug taken and its last dose time, every treatment with route and amount, and the response.

• Pediatrics: oral glucose 0.5–1 g/kg by mouth if the child is alert and swallowing safely (about 10–20 g for a 20 kg child; maximum 25 g). IV dextrose 0.5–1 g/kg of 10–25% dextrose, to a maximum of 25 g, given in incremental doses until mental status improves: 5–10 mL/kg of 10% dextrose, or 2–4 mL/kg of 25% dextrose for children over 8 years. Children under 8 years receive no more than 25% dextrose, and neonates and infants under 1 month no more than 10–12.5% (NASEMSO v3.0, p. 86); neonatal dosing is not covered on this page. See Dextrose. Glucagon IM or SC: 0.5 mg for a child under 20 kg (the kit label also gives 20 to 30 mcg/kg as an equivalent), and 1 mg at 20 kg or more (NASEMSO v3.0, p. 85; kit label). The SC and IV glucagon routes come from the label, not NASEMSO. Nasal glucagon: NASEMSO gives 0.5 mg IM/IN under 20 kg or under 5 years, and 1 mg IM/IN at 20 kg or more or 5 years and older (p. 85). Differs from FDA label: the BAQSIMI label is one 3 mg intranasal device from age 1 year, so the 0.5 mg IN dose is not a labeled nasal dose. NASEMSO also names a prefilled 3 mg dry powder IN device for adults and a 4 mg dry powder IN device for children over 4 years (p. 85); this page does not identify either by product. Gvoke is 0.5 mg for ages 2 to under 12 years weighing under 45 kg (label). Do not give oral glucose to a child who cannot swallow safely. Use weight-based dosing and pediatric vital signs.
• Neonates: Not covered on this page. Thresholds, screening and dextrose doses differ between international and local guidelines. The 70 mg/dL threshold and the doses on this page do not apply to newborns. Treat symptomatic neonatal hypoglycemia immediately, and follow the neonatal protocol. Some current guidance endorses 40% oral dextrose gel as first-line therapy in selected cases.
• Pregnancy: Treat as for other adults. The glucagon label reports that observational studies over decades of use have not identified a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. A rat study showed no embryofetal toxicity. Glucose targets in pregnancy sit in ADA 2026 Section 15, and this page does not restate them.
• Older Adults: Higher risk, and hypoglycemia may be harder to recognize. Cognitive impairment is a strong risk factor, as the 2026 ADA Standards set out.
• Renal Impairment: Kidney failure raises the risk, as the 2026 ADA Standards set out. Sulfonylurea clearance slows in renal impairment, so hypoglycemia may be prolonged.
• Hepatic Impairment: Liver failure is a risk factor for hypoglycemia. Sulfonylurea hypoglycemia may be prolonged in hepatic impairment.
• Obesity: Roux-en-Y gastric bypass carries a late, post-meal hypoglycemia risk. Treat as for other adults.
• Patients on Beta-Blockers: Beta-blockers can blunt the adrenergic warning signs, so hypoglycemia may be harder to recognize. Check glucose rather than trusting the heart rate.

• Error: Treating a symptomatic patient with no glucose value, when one can be measured. Or holding treatment while you wait on a result. Measure when you can. Treat when the picture fits.
• Error: Giving oral glucose to a drowsy or unconscious patient. Oral intake is for alert patients only. Take aspiration precautions.
• Error: Reaching for fat- or protein-rich food as the first treatment. Use glucose.
• Error: Pushing a concentrated dextrose solution into a small or doubtful vein. 10% dextrose works as well as stronger solutions at any age. Children under 8 years receive 25% at most (NASEMSO v3.0, p. 86). And 50% injures tissue on extravasation. Check the site and use the largest vein.
• Error: Stopping after one dose. Recheck at 15 minutes and repeat. Sulfonylurea and long-acting insulin cause recurrence.
• Error: Giving glucagon to a patient with pheochromocytoma, insulinoma or known hypersensitivity to glucagon. Glucagon is contraindicated in these patients. Use dextrose.
• Error: Expecting glucagon to work when liver glycogen is depleted. No response? Give dextrose.
• Error: Giving insulin to a patient who is hypoglycemic. That includes a family member giving a home dose.