|Institut de la francophonie pour la mÃ©decine tropicale|
|Des spÃ©cialistes en santÃ© tropicale|
Auteurs : H.Barennes, Moussa Dicko, Bertrand Graz, Eric Pussard, Merlin L Willcox
Revue / Titre du Journal et Source
Journal of Tropical Pediatrics 2009
Electronic letters published
Rekha and O’Connor, reviewed the evidence of efficacy of sublingual, oral and intravenous glucose in the treatment of hypoglycaemia . After a systematic research using MEDLINE they finally reviewed one trial from Burkina Faso . We thank them for their comments on our study.
This study was the first to show evidence of the efficacy of sublingual sugar, an interesting field practice that we had been promoting since the 1995s in Niger .
Rekha and O’Connor questioned the safety and possibility of side effects in this trial. This point was carefully adressed during the monitoring of patients. Children were monitored at the bed side to ensure the absence of early swallowing and no inhalation side effects or unexpected fit of cough was reported.
Another comment addressed a critical issue : the applicablity in the severely ill child. This important question was answered by the secund study that we conducted in 2006 in Mali .
This study passed through their careful MEDLINE search. Children with hypoglycaemia <60 mg/dl (<3.3mmol/l) and prostrated or in coma malaria were included . 23 children were assigned randomly to receive either intravenous 10% glucose (IVG ; n=9) or sublingual sugar (SLS ; n=14). Blood glucose concentration (BGC) was measured every 5-10 minutes for the first hour. All children were treated for malaria with intramuscular artemether.
The primary outcome measure was treatment response, defined as reaching a BGC of >= 3.3mmol/l (60mg/dl) within 40 minutes after admission. Secondary outcome measures were early treatment response at 20 minutes, relapse (early and late), maximal BGC gain (CGmax), and treatment delay .
The BGC increase was rapid in the SLS group with an overall mean gain of 36 mg/dl (95%CI:17.6-54.5) by 10 minutes. Glycaemia was slower to increase in IVG than in SLS, taking the start time as diagnosis of hypoglycaemia.
About one-third of children had treatment failure in both groups. Treatment failures in the SLS group were related to children with clenched teeth or swallowing the sugar, whereas in the intraveinous group, they were due to unavoidable delays in beginning an infusion. Early swallowing leads to delayed absorption similar to oral route. Relapse was more frequent in SLS group (30%) which justify the recommandation of repeated doses and close follow up. There was also one relapse in intraveinous group due to a blocked infusion an occurrence not so infrequent in the field and often missed.
SLS was painless, well tolerated and no child developed any cough or symptoms suggesting inhalation.
There is now more evidence of the usefulness of sublingual sugar to treat hypoglycaemia in severe illness. A larger study is needed to evaluate the more frequent dosing, and to confirm these results. This treatment is feasible in most children, even if comatose.
This has important implications for the clinical management of children in tropical countries.
1. Ganeshalingam R, O’Connor M. Evidence behind the WHO guidelines : hospital care for children : what is the efficacy of sublingual, oral and intravenous glucose in the treatment of hypoglycaemia ? J Trop Pediatr 2009 ; 55(5):287-289.
2. Barennes H, Valea I, Nagot N, Van de PP, Pussard E. Sublingual sugar administration as an alternative to intravenous dextrose administration to correct hypoglycemia among children in the tropics. Pediatrics 2005 ; 116(5) :e648-e653.
3. Barennes H, Kailou D, Pussard E, Munjakazi JM, Fernan M, Sherouat H et al. [Intrarectal administration of quinine : an early treatment for severe malaria in children ?]. Sante 2001 ; 11(3):145-153.
4. Graz B, Dicko M, Willcox ML, Lambert B, Falquet J, Forster M et al. Sublingual sugar for hypoglycaemia in children with severe malaria : a pilot clinical study. Malar J 2008 ; 7:242.
Conflict of Interest :
Sublingual glucose in hypoglcaemia 28 November 2009 Previous eLetter Top Julian Kelly, University of Melbourne 3052
Send e-letter to journal : Re : Sublingual glucose in hypoglcaemia
We thank Barennes et al for their comment and indeed they highlight a problem for limited search strategy methodology. The role of sublingual glucose is a potentially useful intervention that could have a role in resource limted settings ; there is some evidence as to its efficacy and clearly a larger well designed trial is required. Regarding search strategies, the International Child Health Review Collaboration (ICHRC) (www.ichrc.org) where the WHO guidelines are critically analysed, has now significantly expanded its methodology to include multiple databases rather than relying on the Cochrane collaboration and PubMed, searching grey literature as well as other electronic sources. The WHO in response to greater transparency of process and guideline formulation has developed a Handbook for Guidelines, still in draft form but hopefully soon to be distributed widely for critical appraisal.