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Diabetes

Limestone Learning Foundation
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Health Issues Handbook - Templates and Guidelines

This handbook is an official guideline issued under AP-140, Safe Environments of the Limestone District School Board

Table of Contents

Awareness

What is Diabetes Mellitus?

Diabetes Mellitus is a disease resulting from a lack of insulin. Insulin is a hormone produced in the pancreas. Without it, carbohydrate (starch and sugars) in the food we eat cannot be converted into the energy (called glucose) required to sustain life. Instead the unused glucose accumulates into the blood and spills out into the urine.

Children and adolescents with diabetes are unable to make any insulin and must take insulin injections each day.

At this time no one knows why children develop diabetes. It is known, however, that this disease is not the result of poor eating habits, nor is it infectious.

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 side, lower the blood glucose level by allowing the glucose to be used for energy. Blood glucose testing done by the children 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.

Management and Prevention

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
the food intake will be kept relatively constant. Blood glucose testing may be required by individual students during the course of their school day. 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 school day, but also when on field trips and during detentions and other activities. It is usually possible to co-ordinate 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.

Your children with diabetes may require extra supervision in the lunchroom and on field trips 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 behaviour. 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 detailed information, please refer to the next 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.
Medication
If the child is on medication (the school needs to be aware of this) the Board’s Policy and Procedures needs to be followed, including the completion of all forms related to Policy #E-10 Administration of Medication.

The above documentation regarding medical concerns will assist the school in developing the Emergency Medical Alert form included at the end of this section.

Emergency Treatment

Hypoglycemia (Low Blood Glucose) - An Emergency!

Hypoglycemia is an emergency situation caused by low blood glucose. This situation can develop within minutes of the child appearing healthy and normal.

Causes
  • Low blood glucose usually develops as a result of one or more of the following:
  • Insufficient food due to a delayed or missed meal;
  • More exercise or activity than usual without a corresponding increase in food;
  • and/or too much insulin.
Symptoms
A person who is experiencing hypoglycemia will exhibit some of the following signs:
  • Cold, clammy or sweaty skin;
  • Pallor;
  • Shakiness, lack of coordination (e.g. deterioration in writing or printing skills);
  • Irritability, hostility, and poor behaviour;
  • A staggering gait;
  • Fatigue; and/or
  • Eventually fainting and unconsciousness.
In addition the child may complain of:
  • Nervousness
  • Excessive hunger
  • Blurred vision and dizziness
  • Headache
  • Abdominal pain or nausea
Treatment

It is imperative at the first sign of hypoglycemia to give sugar immediately. If the parents have not provided you with more specific instructions which can be readily complied with, give: 4 oz./125 ml of regular pop (not diet pop); or 4 oz. /125 ml of fruit juice; or 2 teaspoons/10 ml or 2 packages of sugar; or 2 glucose tabs; or 2 teaspoons/10 ml honey. 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, call 911.

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. They are not emergencies that require immediate treatment.

Causes

High blood glucose often develop 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
  • llness.
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 the 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.

Questions and Answers

Can a child with diabetes participate in phys-ed sports?

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 mealtime 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 (See section entitled “Hypoglycemia (Low Blood Glucose) - An Emergency”).

2. How should a child with insulin dependent diabetes be identified by staff.

If the child is an insulin dependent diabetic, they should be identified as part of any school procedure for serious medical conditions.
3. What needs to be in place to meet the needs of a diabetic child?

The student, parent and school share responsibilities in the management and prescription of the child’s diabetic condition. The specifics of the plans need to be in place before the child begins school and be reviewed on an ongoing basis (i.e. change in classroom, child’s condition changes, personal changes, etc).

As a resource for formulating this plan, please refer to the attached, Standards of Care for Students with Type 1 Diabetes in School CDA (1994) Position Paper

Standards of Care for Students with Type 1 Diabetes in School

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.
Severe hypoglycemia

  • 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.
Hyperglycemia

  • 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.
School Responsibility

  • 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.
Family/Student Responsibility

  • 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 Responsibility

  • 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.
Family/Student Responsibility

  • 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 Responsibility

  • 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.
Family/Student Responsibility

  • 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.
Insulin Administration

School Responsibility

  • 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.
Family/Student Responsibility

  • 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
References:
Abridged from the Position Paper of the Canadian Diabetes Association
Prepared by the School Standards Implementation Subcommittee of the National Service Council

CANADIAN ASSOCIATION DIABETES
CANADIENNE ASSOCIATION DU DIABÈTE
1-800-BANTING
1-800-226-8464

Pump Therapy in the School Setting

Insulin pump therapy for the management of type 1 diabetes in children is becoming more common and therefore school staff will encounter young children using this type of therapy and it is important for them to understand it.
An insulin pump is a small external device usually worn on a clip or belt.

It contains a reservoir of rapid acting insulin which flows through a tiny tubing into the child’s body.

The pump is preprogrammed to constantly deliver basal insulin and at meal and snack time an amount of insulin needs to be entered into the pump so that the child’s body can use the sugar from the meal as energy.

In the primary grades children will require assistance with performing this task.

It will be the responsibility of the family to mark the snacks and meal with the carbohydrate count and the dose of insulin to be delivered for the food eaten , and the child’s responsibility to push the “GO” or “ACT” button to deliver the dose.

School staff need to know the basic knowledge about type 1 diabetes especially, prevention, recognition, and treatment of hypo and hyperglycemia.

However there are two major differences between children using insulin by injection and those using the pump.

1.The insulin used in an insulin pump is rapid acting and lasts approximately four hours in the body, therefore it is very important that if the “site” falls out immediate action must be taken to replace it.

2. Because the pump uses only Rapid acting insulin, when blood glucose readings are greater than 14 mmol/L it is important that the child check for ketones.

This can be done through urine or blood testing and if ketones are positive an injection by insulin pen needs to be given and emergency contacts notified.

3. If a child on a pump has a severe episode of hypoglycemia resulting in loss of consciousness after calling 911 the child should be disconnected from the pump at the site.

An individual care plan for each student using pump therapy should be updated yearly by the family and the health care team and shared with the staff of the child’s school.

Insulin Pump Care Plan for Primary Students

Teacher /E.A Responsibilities

1. Know how to lock and unlock the pump
2. Bolus feature and correction bolus
3. How to disconnect at the site.

1-Lock
Press OK button and hold down the up and down arrows at the same time.
Pump locked will appear on the screen.

Unlock -repeat the same steps as lock and the pump will resume the home screen.

Bolus:

1.Unlock the pump
2.Menu in yellow-press OK
3.Bolus in yellow -press OK
4.Normal bolus-press OK
5.00's will flash -use arrows to enter the bolus dose.
When dose is completed, student presses OK (this may require a confirmation call to parent or designate)
6.GO in yellow-student presses OK
For bolus dose follow the chart provided by the parents.

Correction Bolus:
If correction bolus is needed follow the formula using a calculator to determine the correction amount and then add that amount to the meal bolus.

Correction bolus formula is Blood glucose minus --- divided by ----- and the result is the correction amount.

Example -Blood sugar is 18 - = divided by =

Other pump related issues :
Hypoglycemia -low blood sugar -treat with 15 grams of sugar (JR.Juice box)
Repeat test in 15 minutes and if the sugar is not above 5 , disconnect at the site and repeat the juice.
Call parents for further direction.

If hypoglycemia occurs just before lunch, treat and wait till after lunch has been eaten before the bolus is given.
Bolus may need to be reduced so parents should be called.
If the infusion site comes out call parents immediately.
If there are any alarms on the pump call the parents immediately.

Resources and References

The Limestone District School Board is situated on traditional territories of the Anishinaabe & Haudenosaunee.