Care of Children With Diabetes in the School and Day Care Setting
American Diabetes Association
Diabetes is one of the most common chronic diseases of childhood, with an incidence of ~1.7 affected individuals per 1000 people aged <20 years (14). In the U.S., ~13,000 new cases are diagnosed annually in children (58). Only asthma exceeds its prevalence in the school-aged population. There are about 125,000 individuals <19 years of age with diabetes in the U.S. (9). The majority of these young people attend school and/or some type of day care and need knowledgeable staff to provide a safe school environment (1013). Both parents and the health care team must work together to provide school systems and day care providers with the information and training necessary to allow children with diabetes to participate fully and safely in the school experience.
Federal laws that protect children with diabetes include the Rehabilitation Act of 1973, Section 504, the Individuals with Disabilities Education Act of 1991 (originally the Education for All Handicapped Children Act of 1975), and the Americans with Disabilities Act of 1992. Under these laws, diabetes has been determined to be a disability, and it is illegal for schools and/or day care centers to discriminate against children with diabetes. In addition, any school that receives federal funding or any facility considered open to the public must reasonably accommodate the special needs of children with diabetes. Indeed, federal law requires an individualized assessment of any child with diabetes. The required accommodations should be provided within the child's usual school setting with as little disruption to the school's and the child's routine as possible and allowing the child full participation in all school activities.
Despite these protections, children in the school and day care setting still face discrimination. For example, some day care centers may refuse admission to children with diabetes, and children in the classroom may not be provided the assistance necessary to monitor blood glucose and may be prohibited from eating needed snacks. The American Diabetes Association works to ensure the safe and fair treatment of children with diabetes in the school and day care setting (14,15).
Appropriate diabetes care in the school and day care setting is necessary for the immediate safety of the child and for the child's long-term well being and optimal academic performance. The Diabetes Control and Complications Trial showed a significant link between blood glucose control and the later development of diabetes complications, with improved glycemic control decreasing the risk of these complications (16,17). Achieving good glycemic control usually requires a diabetes management regimen consisting of frequent blood glucose monitoring, regular physical activity, and medical nutrition therapy, and may require multiple doses of insulin per day or insulin administered with an infusion pump. Crucial to achieving good glycemic control is an understanding of the effects of physical activity, nutrition therapy, and insulin on blood glucose levels.
School and day care personnel must have an understanding of diabetes and its management to facilitate the appropriate care of the child with diabetes. Knowledgeable personnel are essential if the child is to achieve the good metabolic control required to decrease the risks for later development of diabetes complications. Studies have shown that the majority of school personnel have an inadequate understanding of diabetes and that parents of children with diabetes lack confidence in their teachers' ability to manage diabetes effectively (13,18,19). Consequently, diabetes education needs to be targeted at day care providers, teachers, and other school personnel who interact with the child, including school administrators, school coaches, school nurses, health aides, bus drivers, secretaries, etc.
The purpose of this position statement is to provide recommendations for the management of children with diabetes in the school and day care setting.
GENERAL GUIDELINES FOR THE CARE OF THE CHILD IN THE SCHOOL AND DAY CARE SETTING
I. Diabetes Care Plan
An individualized Diabetes Care Plan should be developed by the parent/ guardian, the child's diabetes care team, and the school or day care provider. Inherent in this process are responsibilities assumed by all parties, including the parent/guardian, the school personnel, and the child. These responsibilities are outlined in this position statement. The Diabetes Care Plan should address the specific needs of the child and provide specific instructions for each of the following:
1. Blood glucose monitoring, including the frequency and circumstances requiring testing.
2. Insulin administration (if necessary), including doses/injection times prescribed for specific blood glucose values and the storage of insulin.
3. Meals and snacks, including food content, amounts, and timing.
4. Symptoms and treatment of hypoglycemia (low blood sugar), including the administration of glucagon, if appropriate.
5. Symptoms and treatment of hyperglycemia (high blood sugar).
6. Testing for ketones and appropriate actions to take for abnormal ketone levels.
Figure 1 includes a sample Diabetes Care Plan. For detailed information on the symptoms and treatment of hypoglycemia and hyperglycemia, refer to the Medical Management of Type 1 Diabetes (20).
Figure 1Diabetes Care Plan.
II. Responsibilities of the various stakeholders
A. The parent/guardian should provide the school or day care provider with the following:
1. All materials and equipment necessary for diabetes care tasks, including blood glucose testing, insulin administration (if needed), and urine ketone testing. The parent/guardian is responsible for the maintenance of the blood glucose testing equipment (i.e., cleaning and performing controlled testing per the manufacturer's instructions) and must provide materials necessary to ensure proper disposal of materials. A separate logbook should be kept at school with the diabetes supplies for the staff or student to record test results.
2. Supplies to treat hypoglycemia, including extra snacks and a glucagon emergency kit, if indicated in the Diabetes Care Plan.
3. Information about diabetes and training in the performance of diabetes-related tasks.
4. Emergency phone numbers for parent/guardian and the diabetes care team so that the school can contact these individuals with diabetes-related questions and/or during emergencies.
B. The school or day care provider should be expected to provide the following:
1. Immediate availability to treatment of hypoglycemia without the necessity for the child to be without direct supervision by a knowledgeable adult and without the necessity for the child to travel long distances to obtain such treatment.
2. An adult and back-up adult trained to be able to: 1) perform fingerstick blood glucose monitoring and record the results; 2) take appropriate actions for blood glucose levels outside of the target ranges as indicated in the child's Diabetes Care Plan; and 3) test the urine for ketones, when necessary, and respond to the results of this test.
3. An adult and back-up adult trained in insulin administration (if needed) in accordance with the child's Diabetes Care Plan.
4. An adult and back-up adult trained to administer glucagon.
5. A location in the school to provide privacy during testing and insulin administration, if desired by the child and family.
6. An adult and back-up adult responsible for the child who will know the schedule of the child's meals and snacks and work with the parents to coordinate this schedule with that of the other children as closely as possible. This individual also will notify the parents in advance of any expected changes in the school schedule that affect the child's meal times or exercise routine. Young children should be reminded of snack times.
7. Training to all adults who provide education/care for the child on the symptoms and treatment of hypoglycemia and hyperglycemia and other emergency procedures.
8. Permission for the child to see school medical personnel upon request.
9. Permission for the child to eat a snack anywhere, including the classroom or the school bus, if necessary to prevent hypoglycemia.
10. Permission to miss school without consequences for required medical appointments to monitor the student's diabetes management. This should be an excused absence with a doctor's note.
11. Permission for the child to use the restroom and access to fluids (i.e., water), as necessary.
12. Appropriate location for insulin and/or glucagon storage, if necessary.
An adequate number of school personnel should be trained in the necessary diabetes procedures (e.g., blood glucose monitoring, insulin and glucagon administration) to ensure that at least one adult is available to perform these procedures while the child is at school or on a field trip.
The child with diabetes should have immediate access to diabetes supplies at all times, with supervision as needed. Provisions similar to those described above must be available for field trips and extracurricular activities to enable full participation.
Members of the health care team should be available to provide instruction and materials to parents to facilitate the education of school personnel. In most circumstances, parents are able to provide the school personnel with sufficient oral and written information to allow the school to provide a safe and appropriate environment for the child. Materials from the American Diabetes Association and other sources are available and have been extremely helpful in accomplishing this goal. Table 1 includes a listing of appropriate resources.
III. Expectations of the child in diabetes care
Children should be able to participate with parental consent in their diabetes care at school to the extent that is appropriate for the child's development and his/her experience with diabetes. The extent of the child's ability to participate in diabetes care should be agreed upon by the school personnel, the parent/guardian, and the health care team, as necessary.
1. Preschool and day care. The preschool child is usually unable to perform diabetes tasks independently. By 4 years of age, children may be expected to generally cooperate in diabetes tasks.
2. Elementary school. The child should be expected to cooperate in all diabetes tasks at school. By age 8 years, most children are able to perform their own fingerstick blood glucose tests with supervision.
3. Middle school or junior high school. The student should be able to perform self-monitoring of blood glucose under usual circumstances when not experiencing a low blood glucose level. By 13 years of age, most children can administer insulin with supervision.
4. High school. The student should be able to perform self-monitoring of blood glucose under usual circumstances when not experiencing low blood glucose levels. In high school, most adolescents can administer insulin with supervision.
At all ages, individuals with diabetes may require help to perform a blood glucose test when the blood glucose is low. In addition, many individuals require a reminder to eat or drink during hypoglycemia and should not be left unsupervised until such treatment has taken place.
1. LaPorte RE, Tajima N, Dorman JS, Cruickshanks KJ, Eberhardt MS, Rabin BS, Atchison RW, Wagener DK, Becker DJ, Orchard TJ: Differences between blacks and whites in the epidemiology of insulin-dependent diabetes mellitus in Allegheny County, Pennsylvania. Am J Epidemiol 123:592603, 1986
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5. American Diabetes Association: Diabetes 1996 Vital Statistics. Alexandria, VA, American Diabetes Association, 1996, p. 1320
6. Dokheel TM, for the Pittsburgh Diabetes Epidemiology Research Group: An epidemic of childhood diabetes in the United States? Evidence from Allegheny County, Pennsylvania. Diabetes Care 16:16061611, 1993
7. Gunby P: North Dakota survey early-onset diabetes. JAMA 249:329, 1983
8. Melton LJ III, Palumbo PJ, Chu CP: Incidence of diabetes mellitus by clinical type. Diabetes Care 6:7586, 1983
9. LaPorte RE, Matsushima M, Chang Y-F: Prevalence and incidence of insulin-dependent diabetes. In Diabetes in America. 2nd ed. Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, Eds. Washington, DC, U.S. Govt Printing Office, 1995, p. 3745 (NIH publ. no. 95-1468)
10. Digon E, Miller W: The Prevalence of Juvenile-Onset Diabetes in Pennsylvania's Schools: Report from the Bureau of Health Research. Harrisburg, PA, Pennsylvania Department of Health, 1976
11. Gorwitz K, Howen GG, Thompson T: Prevalence of diabetes in Michigan school-age children. Diabetes 25:122127, 1976
12. Kyllo CJ, Nuttall FQ: Prevalence of diabetes mellitus in school-age children in Minnesota. Diabetes 27:5760, 1978
13. Wysocki T, Meinhold P, Cox DJ, Clarke WL: Survey of diabetes professionals regarding developmental changes in diabetes self-care. Diabetes Care 13:6568, 1990
14. Jesi Stuthard and ADA v. Kindercare Learning Centers, Inc., Case no. C2-96-0185 (USCD South Ohio 8/96)
15. Calvin Davis and ADA v. LaPetite Academy, Inc., Case no. CIV97-0083-PHX-SMM (USCD Arizona 1997)
16. Diabetes Control and Complications Research Group: Effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977986, 1993
17. Diabetes Control and Complications Research Group: Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 125:177188, 1994
18. Hodges L, Parker J: Concerns of parents with diabetic children. Pediatr Nurse 13:2224, 1987
19. Lindsey R, Jarrett L, Hillman K: Elementary schoolteachers' understanding of diabetes. Diabetes Educ 13:312314, 1987
20. Skyler JS (Ed.): Medical Management of Type 1 Diabetes. 3rd ed. Alexandria, VA, American Diabetes Association, 1998
The recommendations in this paper are based on the evidence reviewed in the following publications: Diabetes Control and Complications Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977986, 1993; and Diabetes Control and Complications Research Group: The effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus. J Pediatr 125:177188, 1994.
The initial draft of this paper was prepared by Georgeanna Klingensmith, MD, Francine Kaufman, MD, Desmond Schatz, MD, and William Clarke, MD. The paper was peer-reviewed, modified, and approved by the Professional Practice Committee and the Executive Committee, November 1998.
Copyright © 1999 American Diabetes Association. Reprinted with permission.
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