Sending any child to school may often cause a parent great anxiety at leaving their little angel in the care of strangers for an extended period of time.  This anxiety becomes ten-fold when sending a child with a chronic illness to school.  No one can possibly care for our child like we do so how do you keep your child as safe as possible when you aren’t there? If you live in the USA, you ensure that you have a 504 Plan in place that outlines the quality of care and responsibilities legally required by the school.  If you live in Canada the road is not as clear.

In Canada, each board has a separate policy.  If your board does not have a Diabetes Policy in place, approach them and ask that it be done.  With the increased number of children being diagnosed with this disease, it is in their best interest to prepare specific policies relating to the care of students with this disease.  Ask to have a say, investigate other policies and try to work out one that is mutually beneficial to all parties.  

Policy or not, 504 Plan or not, your child must still be educated and it is still the parents’ responsibility to do as much as they can to prepare the school to care for their child. Contact your school and ask for an in-service with all personnel who will be in contact with your child.  Have your CDE or public health nurse attend to ensure that everyone  is properly trained and aware of what is involved in having a child with Type 1 diabetes in their school.  If your child is on an Insulin pump, you may wish to show the pump or have pictures of it made available so that everyone understands that it is a piece of medical equipment. 

You may also wish to go over some of the alarms so that staff are aware of what to do even if your child is either too young to understand or not able to communicate at that time.

Ensure that your child wears his/her Medical Alert identification at all times.  Provide your child with an emergency kit—preferably a red box or something else that is easily identifiable.  On the outside of this kit paste instructions for hyper and hypoglycemia.  Also include emergency contact names and phone numbers.  Inside the kit should be such things as fast-acting glucose, glucose gel, ketone strips, spare supplies, etc.  This kit should be kept in a safe place that is known to the child’s teacher and/or aide. 

Ensure that your child has a meter for school that is working and kept well stocked with strips.  If you do not have insurance that covers a spare meter, you might wish to speak with the Customer Service people at the meter company with which you deal.  They will often provide spare meters for such purposes.  A pharmacist may also be able to help with this. 

Finally, you may also wish to provide the school and/or specific teachers with information both general to diabetes as well as specific guidelines for your child’s care.  A bright folder or duo-tang with a photo of your child with diabetes pasted on the cover and the pertinent information on the inside is a good idea.  This folder is then available for supply teachers who will quickly be able to identify the child with diabetes in the class.  Further, for larger schools, a poster with your child’s photo again and information regarding his/her care may also be posted in the staff room so that all personnel are aware of the child and his/her special needs.  You may also wish to print off posters regarding the symptoms of highs and lows to be posted in your child’s classroom as well as in the staff room (these posters can be found in the Kids with Diabetes in Schools package offered by the Canadian Diabetes Association.

Information for packages can be gathered through some of the sites listed below.  Also included on this page are samples of personal guidelines that you may wish to use to outline the care required for your child in school. 

If you have other links or information to add please contact us.

 Sources of Information 

Diabetes is one of the most common chronic illnesses found in school aged children. Despite that, there is a huge need to ensure that your school district, your administrator, and your child's teacher is comfortable and well educated in the way you and your diabetes care team have deemed appropriate for your child with diabetes.  All school personnel who will come in contact with your child must have a basic understanding of the disease. A specific number of staff members should be trained in your child's daily care as well as how to handle emergency care. It is vital that all staff understand that all students with diabetes will need help with emergency diabetes care. This education should be done with both the parents and either a Certified Diabetes Educator (CDE) or your local Public Health Nurse. Whenever possible, have at least two staff members trained in the use of Glucagon. In the case of severe hypoglycemia, one staff member should be administering Glucagon while the other calls 9-1-1 and then the parent/guardian. It is also vital that schools understand the insulin pump if your child is using one. A child on a pump can go into DKA within hours of a pump malfunction and therefore a high must be treated as a serious event as well.

• Diabetes Care Plan

• Canadian Diabetes Association:  KIDS WITH DIABETES IN SCHOOLS offers some great guidelines and posters for hyper and hypoglycemic emergencies. It also brings to attention some of the concerns that teachers may have that need to be addressed by parents.  The “Test Your Knowledge” Section could easily be used to aid in a presentation or inservice with staff.

• www.childrenwithdiabetes.com Information for Teachers provides an excellent overview of diabetes care, terms, and what to do in various situations. 

• Insulin Pump Agreement  written using mg/dl but may be altered to suit individual needs.  

• Insulin Pumpers:  Letter to Teachers and Coaches  This is an excellent and comprehensive letter explaining diabetes, insulin pump therapy, as well as emergency procedures.  It is formatted to be customized to the child’s needs and information.  It is currently written in mg/dl format but can be altered as well.  

• PEDS Online  http://www.pedsonline.org/free_materials.asp   as well as  http://www.pedsonline.org/free_materials/Chapters_1_2.pdf and http://www.pedsonline.org/free_materials/Chapters_5_6.pdf are good sources of general and specific information regarding Diabetes. The above links also contains pages which specifically outline how to treat hyper and hypoglycemia as well as how to prepare and use glucagon and glucose gels.  See page 21 for Glucagon use.

 Samples of Information Provided to Schools  

Diabetes occurs when the insulin producing cells of the body are no longer able to function properly.  In the case of Type 2 diabetes, the insulin produced is not used properly to convert food into energy for the body’s cells.  For those living with Type 1 diabetes, the insulin producing cells have been completely destroyed by the body leaving the person dependent on an external source of insulin given either through injection or subcutaneous infusion via an insulin pump.

What are blood glucose levels and why do they matter?

Your blood glucose level measures the amount of “sugar” in your blood.  It is this “sugar” that acts as fuel for your cells.  In a healthy person, this level should be between 4-7mmol/L after fasting and between 5-10mmol/L 2 hours after eating. For a person with diabetes, the ideal is to be able to artificially maintain these levels.  That is not easy.  They may see levels of high blood glucose--too much sugar and not enough insulin.  This is called HYPERGLYCEMIA.  A person experiencing a “high” will require a lot of fluids to help flush the sugar out of their system.  They will feel the need to use the washroom more often.  Their vision may become blurred and may experience headaches. Left untreated, this will cause a person to develop Diabetic Ketoacidosis (DKA).  DKA results in a chemical imbalance of the blood. If this is not treated quickly and under doctor’s supervision, the person will die. *Hyperglycemia is not immediately dangerous but parents should be notified to help correct the problem from becoming dangerous.  They may also chose to “correct” using the correction feature on the pump.  

A person with diabetes will also see low blood glucose levels as they try to balance food, exercise and illness.  When a person is “low” of HYPOGLYCEMIC, their blood glucose level has dropped below 4mmol/L and they must be treated immediately.  If they are conscious, they can be given some juice or other form of pure sugar to restore a natural balance.  If they are unconscious they must be administered a Glucagon injection to further avoid seizure and possible death. A person recovering from a “low” cannot be left alone.  When someone is hypoglycemic, they are often shaky, disoriented, weak, and may seem tired.  This is a very serious condition that can deteriorate rapidly. 

Can a person with diabetes eat sugar?

As you have already read, all food breaks down into sugar.  A person with Type 1 diabetes has not more dietary restrictions than the average person.  Like a healthy individual, they are encouraged to follow a balanced diet but small treats can easily be added into their meal plan and insulin injected to cover it.  That being said, NEVER give a child with Type 1 diabetes any food without first checking with the child’s parents (this of course does not include the use of food in the treatment of a “low”) While any food can be eaten, it must be measured, given at the proper time and with the correct amount of extra insulin.

Why is diabetes a big deal?

Diabetes currently effects over 2.2million Canadians.  While the majority of those people have Type 2 diabetes, in the province of Newfoundland and Labrador, we have the highest incidence of Type 1 diabetes.  Each month there is at least one child diagnosed on the West Coast of this province alone. This disease leads to kidney failure, heart disease, impotence, blindness, and amputation to name a few.  It does not care about age, these same complications can occur whether the person with diabetes is 70 or 7. 

Currently there is much talk of a cure and the Edmonton Protocol.  While there are many promising avenues of research open right now, we still appear to be a long way from a cure. Advances in therapy through such things as short acting insulin, continuous glucose monitors, and insulin pumps offer hope that those living with diabetes today will be healthy enough to enjoy a cure when it is finally found.  

For further information see:

www.diabetes.ca  The Canadian Diabetes Association

www.diabetesadvocacy.com

www.jdrf.ca  The Juvenile Diabetes Research  Foundation  of Canada

www.insulin-pumpers.ca The Insulin Pumpers of Canada website

What is an insulin pump?

This is what _____s insulin pump looks like.  

An Insulin Pump is a miniaturized version of the device you see in hospital movies attached to a pole that meters bags of "liquid stuff" into the patient's I.V.  An Insulin Pump contains a large syringe filled with insulin, a computer that allows the user to time and adjust the administration of insulin to their bodies, and a small motor to drive the syringe.  Attached to the end of the syringe is a sterile tube (infusion line) fitted with a needle that is inserted into the soft tissue of the lower abdomen or other injection sites.  The entire fluid systems (needle, infusion line, and syringe) must be changed every few days to maintain a sterile environment and avoid infection at the infusion site on the abdomen.

What do you need to know?

The regular cautions of high and low blood sugars are still the greatest importance. It is still vital to watch for odd, clumsy, or lethargic behaviors. Now however, there is a piece of medical equipment thrown into the mix.  This means that care must be taken to ensure no one places with this device.  It is not a toy to be shared, looked at or played with by anyone. This insulin pump has a “lock” feature which stops anyone without the proper code from administering insulin.  It can still be turned off which is a big no no! Below is the message that will be present on the pump face and how to restart the pump.  Restarting it is not a big deal but must be done as soon as possible.  The pump itself will beep after a few minutes of it being turned off. Adults and children around _____ must always be attentive to the tell tale beeps on his insulin pump.  In some cases, it may simply be acting as a reminder in his diabetes in care. In other instances it can indicate a serious problem that must be treated immediately.  The following are some of the alarms that may occur while Liam is in school and details of what should be done.  When in doubt, always call Parent/caregivers' name and phone numbers

Error Messages

Call me immediately.

This is a serious problem. Call me immediately.

This is not a big deal and can wait until Child is at home.  Should you see this please just send a memo home  and I will take care of it.  His pump is set to alarm when he has one day’s insulin left in his pump.

This alarm WILL occur in school.  Have Child press the OK button and ensure that he tests as per the reminder. 

This is only a sample of the alarms that may occur.  Please be keep your ears open should his pump begin to beep. His peers will also be asked to do the same thing. Liam may not always be aware of problems of even it alarming.  It is up to all of us to keep him as safe as possible.  If you have any further concerns, please contact me.

GIVE CONTACT DETAILS HERE

NOTES:

CHILD'S NAME-Health Care Plan 2007-2008

 “Always remember that kids with diabetes are still kids” 

• ______’s blood sugar goal is 130, an acceptable range is 90-160.
• It’s safer to be a little high than a little low, err on the side of caution.
• Check him prior to him eating any food, when arrows are present on his pump, when his blood sugar is below 90 and above 250 and as often as you feel necessary.
• Please don’t reference his blood glucose values as "good" or "bad" -- they're just numbers to help us keep him healthy.  We don’t want him to think a “bad” number is a reflection of something he has done wrong.
• Managing diabetes is an art and a science, so many things affect blood sugar and we don’t have all the pieces of the puzzle so what may work well one day may not have the same effect the next day. The information we are providing are not hard fast rules, but general guidelines. A big dose of common sense and logic along with our guidelines should yield decent, consistent blood sugar values.  

Eating: He can eat whatever any other healthy 5 year old should eat. You have to add up the carbohydrates of the food he is eating and enter the total number into his pump to bolus for the food. You have to give a meal bolus every time he eats, no matter how often, unless you are treating a low blood sugar and you are giving him a 15g carb snack to bring his blood sugar up then you do not want to bolus for the 15 carbs.

To give a meal bolus, hit the ACT button, select BOLUS, enter his blood sugar using the up/down arrows (as long as he hasn’t eaten in the past hour), hit ACT, enter the number of carbs he is eating, hit ACT, select NORMAL BOLUS, it will suggest an amount of insulin. If he has been or will be very active, I would cut it down by a bit (.10-.30), depending on how active he has been or will be. Once you are satisfied with the amount, hit the ACT button and you will see it delivering. It will beep when it is done delivering. So, you can put the pump back in his pocket and listen for the beep. 

To correct a high blood sugar, hit the ACT button, select BOLUS, enter his blood sugar using the up/down arrows, hit ACT,  hit ACT again when the number of carbs screen comes up, leaving it blank --- . It will show you the suggested amount of insulin and you can override if necessary. Please call me if it suggests more than 1.0 units. Once you are satisfied with the amount, hit the right button and you will see it deliver. Again, it will beep once it’s done delivering. 

If his bg is higher than 250 for 2 bg checks in a row which are 30 minutes apart and his blood sugar is not going down. ________ will check for ketones using the keytone meter in her office, it is essentially the same, prick finger, draw blood, it will give you a reading in 30 seconds. If he has any ketones, give him water and call me. You don’t want to drop him more than 100 points in an hour with ketones, it can cause brain swelling. He can develop ketones very quickly on the pump. Exercise is dangerous with moderate to large (over .3) ketones.  He can not participate in gym class if he has ketones over .3. 

Interpreting meter blood glucose numbers;  

*if he has eaten within past 2 hours he may be 200-250, that is fine because it takes 2-3hours for the insulin to fully work. If he is over 280 2 hours after he has had a snack or meal, you should give him insulin via a correction on the pump.

<50 give him 20g fast acting carbs & after a few minutes some cheese & crackers. Then call me, also re-check every 15 mins until he is over 130.  

50-100 give him 10-15g carb & re-check every 30 mins until he is over 130. 

100-150 let him ride if he isn’t doing any heavy activity and you are going to have a snack or meal within 30-40 minutes. Re-check in 1 hour to be sure he hasn’t dropped. If you are not having a snack then you could give him 1 glucose tablet or 2 oz juice just to be safe. 

150-180 do nothing

>180 give a correction according to instructions on previous page. Re-check 1 hour or so after correction and make sure he is going down or at least not still rising, he may remain the same for another hour and that is OK but after 2 hours he should start dropping. If his bg remains high after 2 ½ hours and it’s not going down, call us. We may have to do an injection and a site change. He will have to go to the bathroom more often when he is high, his body is trying to get rid of the sugar. So, you may notice him peeing a lot more when he is high. He will also drink a lot more water when he is high.

Usually when he is low, he gets sweaty, ornery and just plain annoyed. Sometimes he will act completely normal so you never know, when in doubt CHECK. That is the best rule to follow, along with your instincts. He also can get VERY hungry when low, so don’t be surprised if he eats a lot afterwards. That is fine, just bolus him for the food after you’ve treated the low. Remember not to bolus for the carbs needed to bring up the low blood sugar.  

Insulin on board (IOB) - Insulin takes over 3 hours to completely work, his pump is programmed to dose accordingly, it knows how much insulin he still has working in his system, we call this ‘insulin on board’. You can check how much insulin on board he has with his pump, you hit ACT, enter any blood sugar value - it doesn’t matter, hit ACT, skip through the number of carbs leaving it blank, then hit ACT and scroll down to see the value. Then back out of each screen by hitting the ARROW key until you see the home screen.

Sensor- ______’s sensor will show you a blood sugar value every 5 minutes, it will also show you the rate of change with arrows. One arrow means he is going up/down quickly (20-40 points in the past 20 mins). Two arrows means he is going up/down VERY quickly (more than 40 points in the past 20 mins). When his blood sugar is changing quickly, the sensor cannot “keep up” and reflects incorrect values. It is IMPERATIVE to check his blood sugar only with the meter until the two values correlate again. If there are no arrows present then his blood sugar is steady, this is pretty reliable and those numbers are more “valuable”.  When it displays a bg under 90 or above 250, he must be checked with his meter. Before lunch he must be checked with his meter. The sensor data should only be used as a reference and not depended upon as an accurate value. Please see the other information regarding alarms on his pump and sensor.

Parent's name and contact information:

____________________________________________________

____________________________________________________

Child's Name

Type 1 -Insulin Dependent Diabetes Mellitus

9^th Grade

  INSERT CHILD'S PICTURE

(Mom) Contact Number’s:                                      (Dad) Contact Number’s :

     Home: 7XX-XXX-XXXX                                              Work  7XX XXX-XXXX   

     Cell: XXX-XXX-XXXX                                                  Cell XXX-XXX-XXXX

Emergency   #  ____________

Dr, ____________ XXX-XXX-XXXX 

 _______has type I diabetes. Diabetes is a chronic, debilitating disease that can affect every organ system in the body. Type 1 diabetes occurs when the body’s immune system is triggered to react against and destroy the insulin-producing cells in the pancreas. Without the hormone insulin, the body cannot use glucose. As a result, the level of glucose in the blood will rise, causing symptoms. To compensate for the lack of natural insulin, ______ is currently using an insulin pump, which is attached to his body 24/7. He must never remove it. This pump does not regulate his blood sugar levels; it’s just another way to deliver insulin into his body. His Blood sugar levels can still go high or low.

Low Blood Sugar Symptoms

Grouchiness,   Shakiness,  Sweating,  Fast Heart Rate,  Pale skin,  Dizziness,  Yawning,  Sudden moodiness or behavior changes,   Difficulty paying attention,  or  confusion.

If ____  is exhibiting any of these symptoms, and is unable to care for himself,

call the Nurse immediately to the classroom

Accommodations that are necessary:

*_____ shall be permitted to use the bathroom without restriction.

*____ needs to have immediate access to water.

*_____ carries a cell phone and can call his mother, father or Dr. if a medical need arises.

*_______ may need to have juice or a snack in the classroom to treat a low blood sugar.

*_______ must check his blood before gym. His Blood Sugar should be above 150 or he will need to have a snack.  

*_______ will check his blood sugar 30 minutes prior to taking any standardized or classroom test. If he has either high (above 250mg) or low (below 70mg) blood glucose levels at this time, he will be permitted to take the test at another time without penalty and the grade of the re-test will be the one recorded.  Jesse will not take any standardized tests for at least 1 hour after treating a low blood sugar (70 mg/dL or below)

*If _____ needs to take breaks to use the water fountain or bathroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia during a test, he will be given extra time to finish the test without penalty. 

_____ will not be penalized for absences or tardiness required for medical appointments, illness, lateness, visits to the office, or time necessary to maintain blood glucose control.
During a fire drill, _____’s kit (blood glucose meter and treatment for hypoglycemia) MUST accompany him from the building.

Guidelines for Caring for [child's name]

1. When to check blood glucose levels
   1. Two hours after eating
   2. Before and after strenuous physical activity
   3. If he/she says "I'm low," especially if during or after exercise.
   4. If she has symptoms of low blood glucose, including:
      • Irritability
      • Erratic responses to questions
      • Sleepiness
2. What to do based on his/her blood glucose reading
   (Remember, this is only an example and must be adapted to your child's specific needs.)

3. When giving sugar, the following are roughly equivalent:
• Four ounces of fruit juice
• 1/2 to 1 cup of milk
• 2-3 glucose tablets (some are different: 10-15 grams of sugar are recommended)
• One-half tube of Cake Mate (should be placed between the cheek and the gums if unable to swallow)
• One-half of a can of soda (regular, NOT diet!)

Chocolate candy is not to be used unless there is no other source of sugar available. It is often not absorbed quickly enough, due to fats in the candy.

If the blood glucose remains low despite treatment and the student is not thinking clearly, the parents or the diabetes team should be called for advice.

Following an episode of low blood glucoe, it can take several hours to fully recover. While diabetes should never be allowed to become an excuse for school performance, medical evidence shows that the student should not be expected to perform at optimal levels after a “low” or when “high”. 

Based on information found at  http://www.childrenwithdiabetes.com/d_0q_420.htm

Meet Jane Doe:

Insert Picture of

your child here

Meet Jane Doe – 1^st grader in Mrs. Rogers’ class

·        Jane has type 1 diabetes (an autoimmune disorder).

·        Jane wears an insulin pump.

·        A low blood glucose level can come on suddenly, at any time, and can be very dangerous to Jane.

·        Please be aware of the signs and symptoms of low blood glucose levels (see below).

·        If Jane seems low, she should eat a glucose tablet.

·        Jane keeps glucose tablets in her pump pack worn on waist.

·        Additional glucose tablets are available in Mrs. Rogers’ classroom or in the main office.

· If Jane is not coherent or is having a seizure, call 911 immediately!

 Sample of Diabetes School Info
_______  age ___ is a child in your classroom. He has Type 1 diabetes.
He will need to check his blood sugar several times a day while at school. His blood sugar does not stay stable unless he monitors it carefully and frequently. He especially needs to check his blood sugar before eating snacks in the classroom. He may eat anything that is being served,
but he must figure the carbohydrate amount of each food serving and give
 a shot of insulin. ____ may need to be reminded to do his blood sugar check before going to lunch. It is imperative that he checks his blood sugar before eating lunch to ensure that it is in a normal range before
eating.
At times _____ will need to urgently use the restroom,. He may also need to
have a large drink of water, particularly if his blood sugar is elevated,
which you may suggest to him that while he is up getting a drink or using
the restroom to remember to test as getting insulin will quickly lower his
blood sugar level. It takes time for his body to return to normal after being elevated
especially his eyesight, feeling lethargic and brain function. If you have
any questions about this please call me. I am available for this.
______ may need to eat a snack or drink some juice if
his blood sugar levels are low.  He may not feel his blood sugar be low
until it is very low. In this case he must
receive treatment for his blood sugar immediately. If he is unable to drink
from the straw of the juice box, then try giving him the icing tube in his
cheek. I should be called. 
Whenever _____ is outside the classroom he should have his meter and snack
with him at all times including fire drills, other drills, exercise periods,
and field trips.
______ needs adequate time to consume all of his lunch as he will have
gotten insulin for the items he has. Please call me if there is
a problem with him not doing his blood sugar before lunch or not eating his
lunch at the time it occurs, not hours later.
Please allow ______ to call me whenever he feels the need to, it maybe
something he can't explain to you, but I would instinctively pick up on. My
cell phone is available all the time day or night.. CELL # 6XX-1XXX 
At times ______does miss school related to his diabetes. I do encourage him to attend school in a prompt timely fashion and to attend each day.
Please leave a note where substitute teachers can find it that they have a
child with diabetes in their class and this folder where they can at least
refer to if they have any problems or questions.
Please feel free to call me with any problems or questions or more
information that arise.

Thank you,
Cell phone
Home phone

Sample Letter:  

As we begin the new school year, there are a few things I need you to know about my son _____.  _____  was diagnosed with Type One Diabetes in March of 2000.  He is currently on multiple daily injection therapy for the daily treatment of his diabetes.  You will find some detailed information contained in this packet but please only refer to what is below as a quick reference guide. 

 What to Remember: 

Hypoglycemia or Low Blood Sugar must be treated immediately.  ______ may say he feels “low” when his blood sugar is either dropping or already low.  He needs to treat IMMEDIATELY.  ______ has a red box which will hold his meter, lancet, strips, fasting acting sugars, and complex carbohydrates.  ____  may test and treat himself immediately if he feels its necessary and is physically able to do so. There is no time to waste when he feels low.  Please do not send _____ alone or with another child to another area of the school when he feels low.  This is extremely dangerous as he may loose consciousness along the way.  Please feel free to call me at ________ immediately if unsure what to do or advise me once as soon as possible to the occurrence of the low.         

Hyperglycemia   High blood sugar causes damage to the kidneys, eyes and extremities if left untreated for a prolonged period of time. High blood sugar for a child on an insulin pump is often an emergency situation.  Please check with _____'s parents for instructions on correcting the high and checking for ketones.  _____ may usually function without symptoms when his blood sugar is just slightly elevated but he will need to use the bathroom facilities often, is often very thirsty.

   Blood Sugar Testing:  ______ needs to test his  blood sugar at least ___  times during a regular school day.  

               1.    Before Morning Snack:    ____________            am

                    2    Before lunch                   ___________             am

3.    Before Gym:                  ____________            am

4.    After Gym if very strenuous:           ____________            am

5.    Before Afternoon Snack              ____________  pm

6.    Before leaving for home              ____________   pm

If there are any room parties, snacks or treats during the day, please tell me ahead of time so that ______’s insulin can be adjusted or I can make allowances for snacks. NEVER allow _____ to eat any treat without first clearing it with me.          

_____ has no dietary restrictions.  The biggest myth that most people believe is that _____ can not have sugar or any foods containing sugar. Children with Type One Diabetes who properly manage their diabetes and take short acting insulin can enjoy all foods. It is necessary that we know of all treats that are going to be served in the classroom at least one day in advance so that we can adjust ____’s insulin needs accordingly and plan ahead so that ______ can participate in the celebration without any downtime.

Information for Teachers

What is Type 1 Diabetes?

Type 1 diabetes, previously called juvenile diabetes or insulin-dependent diabetes, is an autoimmune disease in which the body destroys insulin-producing beta cells in the pancreas. Insulin is required by the body to use glucose, the simple sugar into which foods are broken down by our digestive system. Without insulin, the body starves to death. It's important to note that everyone is insulin-dependent. People without diabetes make insulin in their pancreas. People with Type 1 diabetes must inject insulin.

High and Low Blood Sugars

Children with diabetes face two problems that teachers need to understand: hypoglycemia and hyperglycemia. You should learn the symptoms and how to treat each.

• Hypoglycemia, or low blood sugar, occurs when the blood sugar level is too low, due to too much insulin, too little food, or too much exercise. Children with low blood sugar sometimes behave erratically or act sleepy, and are often very hungry and shaky. Low blood sugar must be treated immediately by giving the child foods with simple sugars, such as glucose tablets, fruit juice or regular (NOT diet) soda. If you suspect that a child has low blood sugar, do not leave the child unattended because the child can lose consciousness. Never send a child who you suspect has a low blood sugar to the nurse or office alone.
• Hyperglycemia, or high blood sugar, occurs when the blood sugar level is too high, due to too little insulin or too much food. Children with high blood sugar sometimes act lethargic and sleepy, and are often very thirsty and need to go to the bathroom a lot. High blood sugar is treated by giving additional insulin and sugar-free drinks, such as water or diet (NOT regular) soda. Children with diabetes must be given free access to water and the bathroom whenever they feel the need. Prolonged hyperglycemia due to insufficient insulin can lead to a very serious condition called diabetic ketoacidosis, which can lead to coma and death. The length of time required for diabetic Ketoacidosis to occur is dependent on the child and the method of insulin delivery. “Highs” should always be cause for concern as well.

How is Diabetes Treated?

Children with Type 1 diabetes are treated with insulin taken via injections or using an insulin pump, blood glucose monitoring, a carefully managed diet and exercise. Frequent blood glucose tests help determine the correct amount of insulin to take and help identify low and high blood sugars. Children must be allowed to test their blood sugar at school. Testing in the classroom is preferred by many parents, since it minimizes time away from the classroom. Other parents prefer testing in a clinic. Children should be permitted to check their blood sugar whenever and wherever they want.

• Insulin Injections

Insulin must be injected because it is broken down by the digestive system and is rendered ineffective. Insulin syringes tend to be thinner and smaller needles than most people realize and the injections are not as uncomfortable as vaccinations.

Most children with Type 1 diabetes inject insulin several times a day. Some people take two shots, one before breakfast and one before dinner. They use two different kinds of insulin: one short acting and one long acting. Other kids take three or more injections per day, with one shot of short acting insulin taken before each meal, and long acting taken with the pre-breakfast and pre-dinner shots.

Some kids with diabetes use an insulin pump instead of taking injections. An insulin pump is about the size of a pager. Kids can wear it on their belt or carry it in their pocket. A thin tube connects the pump to a small canula (thin tube) inserted under the skin that delivers insulin continuously. Kids who use an insulin pump give themselves insulin to cover each meal that they eat via their pump.

Pen injectors make it easy for kids to do their own injections, either in the classroom or in the office. Injecting through clothing is perfectly safe. Bathrooms are not a good place to do injections because they are often not very clean.

• Blood Glucose Monitoring

Children with diabetes check their blood glucose many times per day. A blood glucose test involves pricking a finger with a lancet and placing a drop of blood on a special test strip. A “glucometers” analyzes the test strip and reports the blood glucose level in less than one minute. This process is called blood glucose testing, blood glucose checking or blood glucose monitoring. They all mean the same thing.

Children with diabetes are usually required to do blood glucose checks during the school day. Many do a check before lunch. Doing a blood sugar check is simple enough that most grade school children can be taught how to do it themselves. Younger kids might need some adult supervision.

There is considerable debate about whether children should do blood sugar checks in the classroom or in another area of the school. Older children are sometimes more conscious of their diabetes, especially if newly diagnosed, and may not feel comfortable checking their blood sugar in the classroom in front of their friends. Kids who are diagnosed very young and know only life with diabetes are often more open about diabetes and are comfortable checking their blood sugar in front of friends. Proponents of in-class checking argue that kids who check in the classroom spend more time in the classroom and are not at risk for having problems while walking to the clinic.

Proper education of teachers and school staff by parents prior to school starting can help eliminate the anxiety many teachers feel regarding in-classroom blood sugar checking. For kids who check in the classroom, parents should provide a glucometer that can remain in the classroom, a lancing device and lancets, a sharps disposal container such as the B-D Home Sharps Container for proper disposal of the lancets, and emergency glucose for treatment of hypoglycemia. Lancing devices and blood glucose meters should not be shared, even among kids with diabetes.

• Meal Planning

Children with diabetes usually follow a meal plan. Meal plans come in many varieties, and is usually tailored specifically to the needs of each child. Parents should provide teachers and day care providers any specific instructions, such as what foods must be avoided and what to do when food treats are brought in by other students.

Parents should also provide morning and afternoon snacks for those children with diabetes who require them. These snacks usually consist of protein and carbohydrates, such as crackers with peanut butter. Children with diabetes who require snacks, but who are not allowed to eat them when required, are at very high risk for hypoglycemia. For these kids, snacks are part of the essential medical care and are not optional.

• Exercise

Exercise is important for all kids, and kids with diabetes are no exception. Diabetes does not prevent a child from participating in any exercise or outdoor activity. Gym class (physical education) and recess can, however, be a challenging time for kids with diabetes since exercise, like insulin, works to lower blood sugar. Teachers should know if a child has diabetes so they can provide help if needed.

Children with diabetes often eat an additional snack before participating in strenuous exercise. A good rule of thumb is 15 grams of carbohydrates for each 30 minutes of exercise.

If gym or recess is immediately before lunch, for example, kids with diabetes should be allowed to eat a snack before participating. Kids with diabetes should be allowed to carry emergency glucose to treat hypoglycemia, especially if they will be outside, far away from the school or classroom. Parents can provide guidelines regarding how strenuous activity will effect their child.

 Adapted from information found at http://www.childrenwithdiabetes.com/d_0q_200.htm

Correction Table for Children Who may need to inject at school

Please note this is strictly an example ONLY!! Please work with your diabetes care team to determine your child's insulin sensitivity factor and apply it accordingly to a similar table for your school.

The first example is in mg/dl for those living in the US and the second is in mmol

SLIDING SCALE FOR INSULINIn addition to the insulin given to cover the carbohydrates in food, sometimes additional insulin must be given to correct _______’s blood glucose levels, if they are high.  This guide tells you how much insulin to give for various blood glucose levels at different times of day.  This insulin is given IN ADDITION to the insulin that is given to cover the carbohydrates in the food _______ eats.

BREAKFAST                                LUNCH

IMPORTANT—IF BLOOD GLUCOSE LEVEL IS OVER 250 AT ANY TIME OF THE DAY_______ SHOULD CALL HOME. _____ may need to test for Ketones. Never exercise when Ketones are present!

SLIDING SCALE FOR INSULIN In addition to the insulin given to cover the carbohydrates in food, sometimes additional insulin must be given to correct _______’s blood glucose levels, if they are high.  This guide tells you how much insulin to give for various blood glucose levels at different times of day.  This insulin is given IN ADDITION to the insulin that is given to cover the carbohydrates in the food _______ eats.

             Breakfast                               Lunch

IMPORTANT—IF BLOOD GLUCOSE LEVEL IS OVER 13mmol AT ANY TIME OF THE DAY_______ SHOULD CALL HOME. _____ may need to test for Ketones. Never exercise when Ketones are present!

This is an example of what may go on the outside of an emergency kit:

If _____'s Blood Sugar Level Is:
Less than 3.0mmol/L give him : one juice box 
then he may also eat some crackers or a meal
3-3.7mmol/L give him: one juice box.
If machine reads HI or LO call me.
If machine reads LO retest immediately and treat for a severe low, which is
anyway you can get sugar into him the fastest, if able to swallow, juice, if
not then icing or the InstaGlucose that he carries

MOM – B_______ 6XX-XXX8 Or 6XX-1XXX (cell phone is always on) 

Supply Teacher Sheet

This is an example of a sheet given to supply teachers or hung in school to identify a child with diabetes and a few very specific points about his/her care.

An Overview of Type 1 Diabetes

Background: Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone. Insulin is produced in the pancreas by the beta cells of the islets of Langerhans. Absence, destruction, or loss of these cells causes an absolute deficiency of insulin, leading to type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). Children with diabetes have IDDM and a lifetime dependence on exogenous insulin.

Type 2 diabetes (noninsulin-dependent diabetes mellitus [NIDDM]) is a heterogeneous disorder. Patients with NIDDM have insulin resistance, and their beta cells lack the ability to overcome this resistance. Although this form of diabetes previously was uncommon in children, 20% or more of new patients with diabetes in childhood and adolescence now have NIDDM, a change associated with increased rates of obesity.

This chapter addresses only IDDM.

Pathophysiology: Insulin is essential to process carbohydrate, fat, and protein. Insulin reduces blood glucose levels by allowing glucose to enter muscle cells and fat cells and by stimulating the conversion of glucose to glycogen (glycogenesis) as a carbohydrate store. Insulin also inhibits the release of stored glucose from liver glycogen (glycogenolysis) and slows the breakdown of fat to triglycerides, free fatty acids, and ketones. Additionally, insulin slows the breakdown of protein for glucose production (gluconeogenesis).

Hyperglycemia (ie, random blood glucose concentration more than 200 mg/dL or 11 mmol/L) results when insulin deficiency leads to uninhibited gluconeogenesis and prevents the use and storage of circulating glucose. The kidneys cannot reabsorb the excess glucose load, causing glycosuria, osmotic diuresis, thirst, and dehydration. Increased fat and protein breakdown leads to ketone production and weight loss. Without insulin, a child with IDDM wastes away and eventually dies from diabetic ketoacidosis (DKA).

Frequency:

·         In the US: Overall incidence is approximately 15 cases per 100,000 individuals annually and probably increasing. An estimated 3 children out of 1000 develop IDDM by age 20 years.

·         Internationally: Many countries report that incidence rates have doubled in the last 20 years. Incidence appears to increase with distance from the equator.

Mortality/Morbidity: Information on mortality rates is difficult to ascertain without complete national registers of childhood diabetes, although age-specific mortality probably is double that of the general population. Particularly at risk are children aged 1-4 years who may die with DKA at the time of diagnosis. Adolescents also are a high-risk group. Most deaths result from delayed diagnosis or neglected treatment and subsequent cerebral edema during treatment for DKA, although untreated hypoglycemia also causes some deaths.

IDDM complications are comprised of 3 major categories: acute complications, long-term complications, and complications caused by associated autoimmune diseases.

·         Acute complications reflect the difficulties of maintaining a balance between insulin therapy, dietary intake, and exercise. Acute complications include hypoglycemia, hyperglycemia, and DKA.

·         Long-term complications arise from the damaging effects of prolonged hyperglycemia and other metabolic consequences of insulin deficiency on various tissues. While long-term complications are rare in childhood, maintaining good control of diabetes is important to prevent complications from developing in later life. The likelihood of developing complications appears to depend on the interaction of factors such as metabolic control, genetic susceptibility, lifestyle (eg, smoking, diet, exercise), pubertal status, and gender. Long-term complications include the following:

·         Retinopathy

·         Cataracts

·         Hypertension

·         Progressive renal failure

·         Early coronary artery disease

·         Peripheral vascular disease

·         Neuropathy, both peripheral and autonomic

·         Increased risk of infection

·         Associated autoimmune diseases are common with IDDM, particularly in children who have the human leukocyte antigen DR3 (HLA-DR3). Some conditions may precede development of diabetes; others may develop later. As many as 20% of children with diabetes have thyroid auto antibodies.

 TYPE ONE DIABETES:  The Balancing Act

The treatment of diabetes can be viewed as a balancing act. Food on the one side, increases the amount of glucose in the blood. Exercise and insulin on the other, lower the blood glucose level by allowing the glucose to be used for energy. Blood glucose testing done by the kids with diabetes or the parents is a means of monitoring the blood glucose balance. When the blood glucose is in proper balance, the child/adolescent will feel well. In terms of academic performance, physical activity and attendance at school, the teacher's expectations of students should be the same as if he or she did not have diabetes.

Food

Maintaining the proper balance of food and insulin is essential to achieving good blood glucose control. When the doctor and parents decide on an insulin dose for the child they are assuming that the food intake will be kept relatively constant.

You do not need to know the details of the meal plan to help kids with diabetes. You must simply understand that the diet for the child is based on the following principles:
eating the same amount of food (carbohydrate content) each day; and
eating meals and snacks at the same time each day.

These principles must be remembered, not only during the regular day, but also when on field trips and during detentions and other activities. It is usually possible to coordinate meal and snack times with typical daily schedules. For example, the child's snack can often be taken at recess or during the class snack time. Occasionally it will be necessary for the student to eat a snack during class and he or she should not be criticized or singled out for doing so. The use of "low noise" food such as cheese or dried fruit will minimize the disruption to the classroom.

Young children with diabetes may require extra supervision in the lunchroom to ensure that they eat most of what has been provided for them. Overeating or eating sweets, will not give rise to immediate problems, but is cause for concern if continued. You should simply advise the parent of such behavior. Missing a meal or snack or eating inadequately, however, is a much more serious problem and can easily give rise to a medical emergency, which requires immediate treatment. This situation, which is the result of very low blood glucose is called hypoglycemia. The appropriate action is immediate treatment with a readily absorbable form of sugar such as juice or regular pop. For more information please refer the section entitled "Hypoglycemia (Low Blood Glucose) - An Emergency!".

With a bit of planning, children with diabetes are able to eat many of the foods that all children love. If parents are notified ahead of time of parties, "hot dog days", or other special events involving food, the kids with diabetes should be able to enjoy them as much as everybody else.

Hypoglycemia (Low Blood Glucose) - An Emergency!

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. 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 classwork. If, however, it is decided that the child should be sent home, it is imperative that he or she be accompanied by a responsible person.

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.
[NOTE: Do not give food or drink if the child is unconscious.
Roll the child on his/her side and seek medical assistance immediately.]

High Blood Glucose

Children with diabetes sometimes experience high blood glucose. The earliest and most obvious symptoms of high blood glucose are increased thirst and urination. If noticed, these should be communicated to the parents to assist them in the long-term treatment. For a child on an insulin pump, high blood glucose levels can quickly become an emergency situation.  Please check with the child's parent or caregiver on child specific instructions for corrections and ketone testing. 

Causes
High blood glucose often develops as a result of one or more of the following:

·         too much food;

·         less than the usual amount of activity;

·         not enough insulin; and/or

·         illness.

Many times, however, there does not seem to be an obvious explanation.

The Sick Child

Kids with diabetes are no more susceptible to infection or to illness than their classmates. They do not need to be in a special "health class" at school. Their attendance record should be normal.

When kids with diabetes become ill with the usual fevers and other childhood sicknesses the blood glucose balance is likely to be upset. Careful monitoring with blood glucose and urine testing, a fluid diet and extra insulin may be required. Such illness management is the responsibility of the parents, not you.

When kids with diabetes become ill at school the parents should be notified immediately so that they can take appropriate action.

Vomiting and inability to retain food and fluids are serious situations since food is required to balance the insulin.

If the child vomits, contact the parents immediately. If unable to reach the parents, take the child directly to the nearest hospital.

Sports and Extracurricular Activities

Kids with diabetes should be encouraged to participate in as many activities as they choose. They should not be excluded from school trips. School sports and extracurricular activities can promote self-esteem and a sense of well-being.

For those kids who wish to participate in vigorous physical activity , good planning is essential so that the blood glucose balance is maintained. The major risk of unplanned vigorous activity is low blood glucose. This can be prevented by eating extra food.

Parents should be notified of special days which involve extra activity so that they can ensure that the child has extra food to compensate.

Sports or other activities that take place during meal time require extra planning. Timing of meals and snacks may be varied and the insulin dose adjusted so that kids with diabetes can safely participate.

It is advisable that both you and the child with diabetes carry some form of fast-acting sugar such as glucose tablets, or juice boxes on outings or sports events.

It is critical that the child's teachers, especially gym teachers and coaches, are familiar with the symptoms, treatment and prevention of hypoglycemia.

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