A new Canadian Diabetes Association position paper makes recommendations for the care of students with type I diabetes in the school system. The purpose of setting such standards is to clearly outline the rolesand responsibilities of parents, students with diabetes and school personnel.
The goals are as follows:
- to provide direction and resources to broaden the understanding of all parties;
- to improve communication; and
- to minimize anxiety on the part of parents and school personnel by taking appropriate steps to ensure the safety, health and success of students with diabetes while they are under school supervision.
Issues of Concern
- School-aged students with type 1 diabetes spend 30 to 35 hours a week in the school setting. This represents more than half of their wakingwe ekday hours.
- School personnel who are knowledgeable in diabetes care can increase students' and parents' satisfaction with the educational experience. Lack of knowledge of diabetes on the part of school personnel can cause apprehension, inappropriate responses during hypoglycemia, restriction of a child's participation in school activities, mistrust, anxiety and poor communication with parents.
- Severe hypoglycemia will occur in 3-8/100 students per year and occur most commonly at night. Severe hbypoglycemia is rare in the school setting. Mild to moderate hypoglycemia is common in the school setting.
- Some school-aged students will be taking multiple doses of insulin, which may include some before lunch at school.
- Hypoglycemia and hyperglycemia may interfere with learning and participation in activities.
- Crises can arise from school personnel inaction, misinformation and rigidity in applying rules that are contraindicated in the management of diabetes.
The following points highlight some specific problems that arise out of lack of understanding of diabetes or misinformation.
Self blood glucose monitoring
- There is often no provision for students to adequately perform selfblood glucose monitoring (privacy, sufficient time, hygienic conditions).
Mild to moderate hypoglycemia
- Symptoms of mild to moderate hypoglycemia can be misinterpreted by school personnel.
- The nature of the emergency is often misunderstood, placing a student at serious risk.
- Some students are disciplined or punished for behaviours that are associated with hypoglycemia or hyperglycemia which should be seen as cues to treatment.
- Conflict regarding when and where a student may eat to treat a low blood glucose reaction and who is to supply the treatment (food or gel) can create confusion and delay treatment, placing the student at risk.
- Some families expect school personnel to administer glucagon, some to call emergency service.
- Glucagon administration is especially problematic as the procedure is invasive and may exceed the authority set by school policy. Supply and storage issues are complex, training is highly technical, and the procedure is often viewed with anxiety and resistance by people not involved in healthcare.
- Some students are inappropriately disciplined for behaviours associated with hyperglycemia (i.e. requests to go to the bathroom or requests for frequent drinks)
The following standards recognize the essential partnerships among the student, family and school personnel.
Communication and Education
Family/Student/School Shared Responsibility
- Frequent communication between school personnel and parents is essential, especially for changes in school activity, special events or snacks (including home economics classes), to avoid high or low blood glucose.
- Parents and school personnel must regularly review prevention, identification and treatment of low blood glucose, as well as emergency procedures for treating moderate to severe low blood glucose.
- Parents are generally the best people to provide specific information about their child/adolescent. A school administrator and identified key school personnel in contact with students with type 1 diabetes must receive education. The school administrator will be responsible for disseminating information to other school personnel.
- Diabetes education teams may be involved when language, cognitive ability, behavioural issues or serious psychosocial barriers exist. Diabetes education inservices for school personnel may also be available to support the parent's education of school personnel.
- There must be a formal communication system in place that includes all school personnel who are in contact with the student with diabetes at school.
- The student with diabetes must be clearly identified, for example, with a photograph to which all school personnel can refer. A copy of emergency and treatment procedures must be readily available for all staff to refer to.
- There must be flexibility in school rules to ensure that the student can prevent or treat low blood glucose. The student may have to eat on the bus, at his or her desk, not participate temporarily in certain activities, ask for assistance, etc.
- School personnel are encouraged to seek opportunities to learn more about diabetes.
- Students with diabetes can participate in all school activities. The safety of the student must be ensured by providing adequate supervision at such special events as field trips, parties, intramural sports, etc.
- Families must strongly encourage their student to wear diabetes identification (e.g. Medic-Alert™) at all times. Diabetes identification speaks when the student cannot, and it provides vital information.
- Some students are interested in and willing to do presentations to classmatesand participate in "teaching the teachers." When appropriate, this should be encouraged.
Blood Glucose Monitoring
- School personnel are not expected to participate in blood glucose monitoring unless there is mutual agreement, and separate training has been provided forid entified school personnel in contact with very young students or with students with special needs who cannot do blood testing by themselves.
- Laws vary from province to province aboutwho is legally permitted to draw blood. Schools should be informed about the laws in their particular province.
- Students who are able can do blood glucose monitoring as necessary in a designated area in the school or classroom. Students must be allowed enough time and have access to a clean, private space to test their blood.
- Arrangements must be made for safe disposal of lancets and needles. Disinfecting of the blood glucose monitoring areas with appropriate cleaners should be done according to school policy regarding blood and body fluid precautions.
- Parents, not school personnel, are responsible for making treatment decisions based on results of blood glucose monitoring unless a special arrangement is made between the parents and the school personnel.
- If parents have arranged for school personnel to make management decisions, it is critical that they provide clear guidelines for prevention and treatment of hypoglycemia.
Hypoglycemia (Low Blood Glucose)
- School personnel must endeavour to ensure that students eat all snacks and meals, fully and on time. This is especially important in elementary schools for younger students and those with special needs.
- Students must be permitted to take oral glucose to prevent or treat low blood glucose anywhere on school property, on buses or during school-sanctioned activities.
- Students should not be left alone for at least 30 minutes after the treatment of low blood glucose. Until the student is fully recovered, he/she should not be leftunsupervised. Once the recovery is complete, the student can assume regular classwork. If, however, it is decided that the student should be sent home, it is imperative that he/she is accompanied by a responsible person.
- School personnel must contact the parents immediatelyafter treatment of moderate or severe low blood glucose.
- School personnel must contact the parents immediately if the student is unable to eat or vomits at school.
- Where necessary, arrangements must be made to safely store an accessible supply of glucagon.
- The school must provide for safe and accessible storage of the student's food supplies.
- Parents or designates must discuss low blood glucose with school personnel (i.e. causes, prevention, identification, treatment). This must include highlighting special signs or characteristics in the student.
- Parents or designates must review emergency procedures for treating moderate to severe low blood glucose annually and as needed with school personnel (e.g. new staff).
- Parents or designates must provide an extra snack as well as a constant supply of fastacting sources of sugar at school to prevent and treat low blood glucose. Supplies must be kept in several locations throughout the school, such as the homeroom, gym, principal's office and teacher's room as mutually agreed upon by the family/student and the school
- Oral glucose is not considered a medication. If this is contentious, a blanket consent form (which authorizes the school to give the oral glucose) can be provided by the parents at the beginning of the school year.
- School personnel are not responsible for treating severe low blood glucose with glucagon. In exceptional circumstances (e.g. in isolated areas where emergency medical services may be unable to respond quickly enough and where school personnel agree parents or designates may provide training in how to inject glucagon. In these unusual cases, parents must provide and replace a glucagon kit with the expiry date clearly marked.
- School personnel are not responsible for giving insulin injections.
- School personnel must ensure that the student has time and a clean, private space to self-inject insulin if necessary.
- School personnel must make arrangements for the safe storage of insulin and syringes/pens if necessary
- School personnel must arrange for the safe disposal of lancets, syringes, test strips, etc. This may mean that a container for sharps is provided by a school nurse or parents, or that the student transports sharps home for disposal.
- If the student requires insulin during school time, the student and family are responsible for performing this aspect of diabetes care.
- Family and student must safely dispose of sharps at school or transport sharps home for disposal