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Hypoglycaemia at glucose concentrations of less than 60 mg/dl (<3 mmol/l) can result in neurologic signs including seizures. Clinical signs vary depending on the rate of decrease, magnitude and duration of hypoglycaemia and include behavioural changes, altered mental status, nervousness, tremors, generalized weakness and seizures. Severe brain damage, coma and death may occur with glucose concentrations of less than 18 mg/dl (<1 mmol/l). As with other homeostatically regulated parameters, the onset and severity of neurological signs may depend more on the rate of decrease than the actual concentration of glucose. Clinical signs may be triggered by fasting or exercise. There are multiple causes of hypoglycaemia (Box 4.1).