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Proposed Policy Regarding the Care of Children With Diabetes in Canadian Public Schools Created by Diabetes Advocacy, after consultation with teachers, Special Educators, School Principals, and parents. November 2004 Table of Contents Page
Appendix
Proposed Policy Regarding the care of Children with Diabetes in Canadian Public Schools 1. Introduction Type 1 Diabetes, also known as Insulin Dependent Diabetes Mellitus or Juvenile Diabetes is an auto-immune disease that occurs when the beta cells of the pancreas produce little or no insulin. Insulin is a hormone which is essential for processing glucose in the body. When insulin is present, glucose can be used by the body for energy and unused glucose can be stored for later use. Lack of insulin causes glucose to remain in the blood. It is then filtered through the kidneys and spilt in the urine. If the body cannot get glucose, it will begin to look for an alternate method of energy by breaking down fat and muscle. This breakdown causes the release of toxins called ketones which are very dangerous to a person with diabetes. The treatment of Type 1 Diabetes requires a careful balance of diet, exercise and insulin. Since insulin cannot be produced by someone with Type 1 Diabetes, it must be injected. Daily doses of insulin either through injections or an insulin pump allow a person with diabetes to live a relatively normal life. Insulin injections are based on blood glucose levels, nutritional analysis of food eaten, as well as calculation of activities that will be occurring or have previously occurred. Should the person with diabetes be given too much insulin, they will become “hypoglycemic” or “low”. Hypoglycemia is considered to occur when the blood glucose level drops below 4.0mmol/L. This is an emergency situation which requires immediate treatment with a fast-acting sugar such as regular pop, juice or glucose tablets. If treatment is not immediate, the person with diabetes may become unconscious. At that point, they must receive an injection of Glucagon® or risk brain damage or possible death. If a person with Diabetes has too little insulin injected into their system, they will become “hyperglycemic” or “high”. Hypoglycemia is considered to occur when fasting blood glucose levels are above 8.0mmol/L or blood glucose levels are above 10.0 mmol/L within 2 hours of eating. This is also a serious situation. In this case, the person may have blurred vision, become lethargic, have an unquenchable thirst, and need to constantly use the washroom. They will require more insulin to be injected into their system. In the case of children with diabetes, it is important to note that optimum learning occurs when blood glucose levels are between 4.4-8.3 mmol/L. The human brain is almost totally dependent on a continuous supply of glucose. Both hyperglycaemia and hypoglycaemia may cause physical, affective, and cognitive symptoms, as well as cognitive-motor disruptions. Even relatively mild levels of extreme blood glucose—either hyperglycaemia or hypoglycaemia—according to a 2002 study, cognitive functioning may decay by one third. According to B.M. Frier’s September 2001 study “cognitive function does not recover fully until 40-90 minutes after blood glucose is restored to normal.” Physical activities such as a physical education class also require special considerations for the child with Type 1 diabetes. As noted in the 2002 article by H. Dorchy, “In the young diabetic, during insulin deficiency, and therefore in a poor degree of metabolic control, i.e. Hyperglycaemia and ketotic, exercise accentuates hyperglycaemia and ketosis, leading to extreme fatigue. If the insulin dosage is too high, the increase in muscular assimilation, combined with the shutdown of liver glucose production, may result in a severe hypoglycaemia. During the recovery period, repletion of muscular and hepatic glycogen stores may also provoke a hypoglycaemia during hours after the cessation of muscular work.” 2. Purpose 2.1. To provide school personnel in the province of Newfoundland and Labrador with information and guidelines regarding the requirements of care for students with diabetes. 2.2. To provide information about the management of risks associated with diabetes for all involved parties. 2.3. To develop an information and resource manual for school personnel about the management of diabetes in school children. 2.4. To establish the roles of the school, the parents, and the child in this process. 3. Application 3.1. This policy will apply to all schools in the province of _________________ 4. Definitions 4.1. Type 1 Diabetes (also known as Insulin Dependent Diabetes Mellitus or Juvenile Diabetes): occurs when the insulin producing cells of the pancreas no longer function leaving those affected dependent on an external source of insulin in order to survive. There is currently no cure. 4.2. Insulin: A hormone produced by the beta cells that allows food to be converted to glucose which is then used as fuel for the body. 4.3. Type 2 Diabetes: occurs when the body is no longer able to properly use the insulin it is producing. Type 2 Diabetes is often controlled through diet and exercise. In some cases pills or injections of insulin may be required. 4.4. Gestational Diabetes: affects approximately 4% of pregnant women and usually goes away after the baby is born. 4.5. Glucagon: A chemical hormone produced in the pancreas. It mobilizes stored sugar and causes the blood sugar level to rise. It is used to treat severe hypoglycaemia and must be given by injection. 4.6. Hypoglycemia: a blood glucose reading of under 4mmol/L. This may also be called an “insulin reaction”. Hypoglycemia is a medical emergency and can lead to seizures and death if not treated properly. Symptoms occur when the body gets too much insulin, too little food, a delayed meal or snack, or more than the usual amount of exercise. Symptoms include: tremors, sweating, light headedness, irritability/mood changes, confusion, drowsiness, hunger, paleness, blurred vision, the decreased ability to concentrate. The student will need to ingest carbohydrates promptly and may require assistance. Treatment options are set out in the Diabetes Emergency Treatment Protocol. 4.7. Hyperglycemia: a blood glucose reading of over 10mmol/L. High blood glucose levels can affect student learning. Hyperglycemia occurs when the body gets too little insulin, too much food, or too little exercise; stress or an illness such as a cold may also cause it. Symptoms include thirst, frequent urination, blurry vision, tiredness, decreased ability to concentrate, irritability/mood changes. If untreated for a number of days, hyperglycemia can cause a serious condition called Diabetes Ketoacidosis, which is characterized by nausea and vomiting. This condition can be life threatening. This situation may appear in a matter of hours in children using insulin pumps rather than multiple daily injection therapy. Parents or caregivers should be made aware of the situation so that steps may be made to correct it in the future. 4.8. Buddy: for the purpose of this document, a buddy is defined as a child who will be allowed to accompany the child with diabetes to the office or other times that require the child with diabetes to leave the classroom unattended. The role of the buddy will simply be to assist the child with diabetes by obtaining adult assistance should the child become weak or disoriented when away from the classroom. 4.9. Non Emergency Situations: include routine care such as blood glucose testing and the administering of insulin injections. 4.10. Emergency Situations (Life Threatening): occur when a student suffering from low blood sugar is unable to administer the appropriate treatment because they are unresponsive or unconscious. Immediate action is required. 5. Responsibilities 5.1. Responsibilities of The Principal 5.1.1. Upon notification that a child with diabetes will be attending their school, the principal will arrange to meet with the parents to discuss the details outlined in this policy and to complete the Diabetes Emergency Treatment Protocol Registration. A folder will then be made available to all staff and substitute personnel. 5.1.2. The principal will arrange an annual in-service for all staff members who will supervise any children with diabetes during the school year. This in-service will involve instruction on care from the Public Health Nurse or a Certified Diabetes Educator, as well as the parents of all children with diabetes. Sessions will include the treatment of hypoglycemia, hyperglycemia and Glucagon administration 5.1.3. Personnel trained in Glucagon Administration will be identified in the Diabetes Care Plan. 5.1.4. The principal will ensure that at least 2 staff members are trained to administer Glucagon® in case of severe hypoglycemia. 5.1.5. The principal will ensure that all staff are aware of the children with diabetes and respond appropriately to all diabetes related emergencies. Personnel will be instructed to remain with the student until appropriate treatment has been administered and blood glucose levels are stabilized. 5.1.6. The school will allow flexibility in the student’s class routine/school rules to ensure that the student with diabetes can appropriately manage his/her diabetes. Situations may include allowing the student to eat on the bus or at his/her desk, not participate temporarily in certain activities, ask for assistance from school personnel, etc. 5.1.7. The principal will work with the parent(s) to ensure that a plan is developed regarding the supervision of children with diabetes on field trips. If the parent is able, they should be allowed to accompany their child on all such outings if they wish. 5.1.8. The principal shall work with the Department of Health to ensure that there are proper storage containers available in the school for the disposal of syringes, lancets and other medical waste. 5.1.9. The principal shall ensure that hypo- and hyperglycemia posters are posted in specific areas of the school to aid in recognizing the signs and symptoms of these reactions. 5.1.10. The school will designate personnel to notify the parent/caregiver if the student does not eat all scheduled meals and snacks (age appropriate) or vomits. 5.1.11. The principal will make sure a medic alert sticker is placed on the tab of the student's cumulative school file and beside their name on the homeroom register. 5.2. The Teacher 5.2.1. The teacher will ensure that all blood glucose levels, insulin dosages, and treatments are logged properly in a book provided by parents. 5.2.2. The teacher will inform the parent at least 3 days in advance of all class parties, extra snacks, bake sales or treats. 5.2.3. The teacher will introduce diabetes into the classroom to foster acceptance and understanding in an age appropriate manner. 5.2.4. The teacher will advise parents at least 3 days prior to any change in activities such as playtimes or lunchtime schedules. 5.3. The Parent 5.3.1. The parent will advise the school of their child’s diagnosis. 5.3.2. The parent will fill out an Emergency Procedure Protocol Form for their child with diabetes. 5.3.3. The parent will participate in the in-service for staff regarding the care of children with diabetes in school. 5.3.4. The parent will ensure that the child has insulin, syringes, glucometers, test strips, treatment for hypoglycemia, glucagons and other diabetes related supplies at school. 5.4. The Student 5.4.1. The student will be responsible for wearing Medic Alert identification at all times. The school will not require this identification to be removed for any reason. 5.4.2. The student will carry their supplies with them at all times. 6. Accommodations 6.1. Children with diabetes will be able to keep a bottle of water with them at all times 6.2. Children with diabetes will have unrestricted access to washrooms. 6.3. Children with diabetes will be able to eat snack in the classroom 6.4. Snacks and meals for children with diabetes will be eaten at the same time each day. Should there be any change in this routine, the parent will be told at least 3 days in advance. 6.5. Children with diabetes may leave the classroom for diabetes related issues 6.6. Children with diabetes should not leave the classroom unattended but should have a “buddy” assigned to them at the beginning of the year who will accompany them. 6.7. Children with diabetes must have immediate access to all diabetes related supplies. 6.8. Children with diabetes must be provided a safe and clean place to test their blood glucose levels. If the child feels comfortable, this may be done in the classroom to minimize disruptions. 6.9. Children with diabetes will be allowed to inject their insulin whenever and wherever it is necessary. This again can be done in the classroom or in a separate room as decided upon by the parent and principal. All syringes will be disposed of properly in the provided containers. 6.10. Children with diabetes will be supervised by a staff member when administering insulin to verify that the correct dosage has been given. 6.11. Children with diabetes in primary and elementary school grades will be monitored by a staff member when eating snacks or meals to ensure that all of their food is eaten and no food is shared with other children. 6.12. Children with diabetes will be given adequate time to finish all of their snacks or meals without punishment. 6.13. Children with diabetes will be able to participate fully in Physical Education classes and extra-curricular activities. 6.14. Children with diabetes will be excused from Physical Education classes if their blood glucose levels are over 16.5 mmol/L with ketones present or have a blood glucose level below 4 mmol/L. 6.15. Children with diabetes will be able to test their blood glucose levels before all examinations and standardized tests. They will be able to rewrite examinations if their blood glucose levels are over 12.2 mmol/L or below 4 mmol/L at test time. 6.16. Children with diabetes will not be penalized for time spent on diabetes related activities when performing an exam or completing a classroom assignment. 6.17. Children with diabetes will not be penalized for diabetes related absences. 6.18. Children with diabetes will be allowed to carry with them a cell phone for the purpose of contacting parents regarding diabetes care only. The phone may be turned off when not in use. 7. Common Law Duty Of Care And Related Obligations 7.1. All school personnel shall help a student in an emergency situation to the best of their ability. The common law duty of care obligates school system employees and volunteers to take action in support of the physical well-being of students under their care. Employees must act, as would a careful and prudent parent of a large family in the same circumstances. It is, however, not to be construed that all the authority of a parent or guardian is conferred upon employees. 7.2. Qualified Medical Help and Ambulance Use In the event where school personnel judge a situation, as a medical emergency, qualified medical help shall be sought immediately. Ambulance fees will be assumed by the parent. Diabetes Care Plan
Province of Newfoundland and Labrador
Diabetes care Plan for ____________________________________________________ School__________________________ Effective Dates__________________ Date of Birth______________ Grade______ Teacher_________________
Contact Information
School to contact the parents in the following situations 1._______________________________________________________________ _______________________________________________________________ 2._______________________________________________________________ _______________________________________________________________ 3._______________________________________________________________ _______________________________________________________________ 4._______________________________________________________________ ________________________________________________________________ 5._______________________________________________________________ _______________________________________________________________ Hypoglycemia Usual symptoms___________________________________________________ Treatment for hypoglycemia ________________________________________ _________________________________________________________________ Diabetes Care Plan cont’d Location of Hypoglycemia Kit__________________________________________ Glucagon Treatment for severe hypoglycemia □yes □ no Location of Glucagon Kit _____________________________ School Personnel Trained to administer Glucagon and dates of training
Hyperglycemia Usual Symptoms ____________________________________________________ Treatment for Hyperglycemia _________________________________________ ___________________________________________________________________ Test for ketones in blood or urine when blood glucose level is greater than _____mmol/L Test for ketones when student is feeling sick? □yes □ no Procedure for ketone testing__________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Where are the following Diabetes Supplies kept? Blood Glucose Kits __________________________________________ Insulin Administration supplies _________________________________ Hypoglycemia Treatment kit ___________________________________ Glucagon Kit _______________________________________________ Ketone Testing equipment _____________________________________ Snack foods ________________________________________________ Blood Glucose Monitoring Protocol Student’s target range is between _________mmol/L and ________mmol/L The usual times to test during school hours are ___before class begins ___before lunch ___two hours after meal ___before recess ___after outdoor play ___before gym class ___before going home Times that require extra testing ___before exercise ____when hypoglycemic symptoms are present ___after exercise ____when hyperglycemic symptoms are present ___other (explain)__________________________________________ Can student test him/herself on their own? ____yes ____no Exception_________________________________________________ School Personnel Trained to monitor blood glucose levels
Insulin Administration Times, type and dosages to be given in school
Is the child able to inject or bolus insulin on their own? ____yes ____no If no, indicate personnel trained to inject insulin
Is the child able to determine the correct amount of insulin to be used on their own? ___yes ____no Is the child able to draw up the required amount of insulin on their own? ___yes ___no Diabetes Care Plan Cont’d If the child is using and insulin pump Can the child operate his/her pump? ___yes ___no Can the student handle pump malfunctions? ___yes ___no Who should be contacted in case of pump malfunction? ___________________________________________________ ___________________________________________________ Comments __________________________________________ ___________________________________________________ ____________________________________________________
Meals and Snack foods
Snack required before exercise? ___yes ___no Type of snack required ________________________________ Snack required after exercise? _____yes ___no Type of snack required ________________________________
Foods to avoid ___________________________________________________ ___________________________________________________ ___________________________________________________ Instructions for when food is provided to the class: _________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Exercise and Sports Student should not exercise when blood glucose level is below ____mmol/L or above _____mmol/L Signature of Parent/Guardian____________________________Date___________ Signature of Principal _________________________________ Date___________
Treatment Protocol When in doubt TREAT!
It may take some coaxing to get the child to eat or drink but you must insist. If there is no noticeable improvement in about 10 to 15 minutes repeat the treatment. When the child's condition improves, he or she should be given solid food as dictated by the parent. This will usually be in the form of the child's next regular meal or snack. Until the child is fully recovered he or she should not be left unsupervised. Once the recovery is complete the child can resume regular class work. If, however, it is decided that the child should be sent home, it is imperative that a responsible person accompany him or her. Parents should be notified of all incidents of hypoglycemia. Repeated low blood glucose levels are undesirable and unnecessary and should be drawn to the parent's attention so that they can discuss the problem with their doctor If unsure whether the child is hypoglycemic, always give sugar! A temporary excess of sugar will not harm the child but hypoglycemia is potentially serious. Kids With Diabetes In Your Care – Canadian Diabetes Association Emergency Procedure for Severe Low Blood Glucose Hypoglycemia/Insulin Reaction Glucose Gel Followed by Glucagon Injection
Pupil: DOB: School: Grade:
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