School Health Alert
SHA: What types of diabetes are of concern to the school age population?
Dr. Ponder: Until recently, type 1 diabetes was the only form of diabetes most school personnel needed to be familiar with. However, the dramatic rise of type 2 diabetes (formerly called adult onset diabetes) in children and adolescents over the past decade has led to a new paradigm. Virtually any type of diabetes can now affect the school age child or teen. Each type of diabetes carries with it slightly different considerations. For example, the child with type 1 diabetes (formerly termed juvenile onset diabetes) would be expected to require insulin by injection for the rest of his/her life. In addition, hypoglycemia (low blood sugar) is a constant concern which demands the vigilance of all school personnel involved with the student with diabetes. On the other hand, children with type 2 diabetes are typically overweight and are often treated with oral agents instead of insulin, although insulin may be successfully used in the child with type 2 diabetes. Proper control of diabetes with an emphasis on exercise and changing nutritional habits are cornerstone therapies of type 2 diabetes of any age, but are even more relevant to the child with type 2 diabetes, who is often faced with significant excess weight and all its consequences on health and well being.
SHA: What is the latest research on the causes of diabetes in children and youth?
Dr. Ponder: The various types of diabetes have different root causes. Type 1 diabetes is the end result of an autoimmune mediated destruction of insulin production at its source. For still poorly understood reasons, the immune system mistakenly recognizes insulin producing cells (called beta cells) as foreign. This precipitates a focused, chronic, immunologic attack destroying the body’s sole source of insulin. There is a genetic susceptibility which places a person at risk for developing autoimmunity, but a variety of environmental factors has been implicated in the initiation and maintenance of the autoimmune attack against the beta cells.
Without insulin to permit entry of glucose into body tissues, blood sugar levels rise to abnormally high levels and symptoms of diabetes begin to appear. The absolute lack or deficiency of insulin underscores the fact that only insulin therapy by injection (or an insulin pump) constitutes clinically effective treatment. Oral medications do little to nothing to improve the blood sugar control and are in fact dangerous to use in a child for whom insulin is the only proper therapy.
The child with type 2 diabetes has a different pathophysiology. Insulin supply (from the pancreas) cannot keep up with insulin demand. The lack of effective insulin action results in increased glucose output from the liver and failure of skeletal muscle glucose uptake. The end result is high blood sugar. So the cause of type 2 diabetes is a combined effect of insulin resistance and insulin secretory failure. Insulin resistance has a genetic basis which can be worsened by obesity and relative inactivity. It remains a mystery why insulin secretory failure can strike at vastly different ages.
SHA: What are the key components of care for a child with type 1 diabetes?
Dr. Ponder: It’s been stated that the person with diabetes who knows the most, lives the longest. While the self care skills of exercise, proper nutrition and medication have been the tools to maintain adequate control of the blood sugar level, they ultimately rest on a foundation of diabetes self management education. The child with diabetes is the center of all efforts and ultimately determines their success of failure. The family and school play invaluable roles to the success of any management plan. The student with diabetes constantly makes self care decisions each day. These choices either maintain or undermine overall control. One self care skill performed in the school is blood glucose monitoring. The student must be allowed to perform this vital task in order for proper self care choices to be made (e.g., insulin dosing). Furthermore, the information gathered is critical to maintaining long term control since it provides feedback to the student’s medical team to guide any therapeutic adjustments which might be necessary
SHA: What should a care plan at school include and who should be involved?
Dr. Ponder: Roles and responsibilities are the order of the day. These are defined by the age and maturity of the student, coupled with their level of day to day involvement in making management decisions at home. At a minimum, each secondary school teacher should be aware that a child with diabetes is in his/her classroom. Primary school teachers should be more familiar with the student’s individual needs and should arrange a meeting with the parents and school nurse (if available). The rights of the student should be clear to all parties. These include the right to free access to water and a bathroom, the right to perform blood sugar testing in an appropriate location, the right to consume snacks at the appropriate times, and the right to treat low blood sugar whenever it occurs.
SHA: How do schools plan for safe care and involve the appropriate staff but maintain the student’s privacy and confidentiality of information?
Dr. Ponder: This starts with a meeting with the family, teacher(s), school nurse and perhaps a representative of the child’s diabetes care team. The student may need a quiet, supervised location to perform his/her self care skills with no disruption. Some students may waive this right to privacy from time to time depending on circumstances. Nevertheless, if the child feels self conscious, he/she should be allowed access to surroundings conducive to proper performance of their self care skills.
SHA: What are some guidelines for meals and snacks during school and with after school programs?
Dr. Ponder: Meals and snacks, plus their proper timing are integral to optimal blood sugar control. The meal plan is determined by the physician in collaboration with a dietitian. The parents are often the messengers of this information to school personnel. The timing of snacks is intended to coincide with times of peak insulin activity. Furthermore, the child’s insulin dose is “balanced” with a certain expectation in regards to food. The macronutrient most important to maintaining blood glucose levels is carbohydrate. Approximately 95-100% of ingested carbohydrate is converted into glucose by two hours post ingestion. The meal plan of the student with diabetes takes this into account and “prescribes” a specific quantity of carbohydrate to be consumed each day, apportioned between 3 meals and 2-3 snacks. Parents are encouraged to pack snacks for the student or guide the student’s selection of suitable snacks and meals. After-school personnel should make sure the student consumes the afternoon snack. Failure to do so increases the risk of low blood sugar. “Time-released” insulin (by injection) demands certain adjustments be made regarding food intake in order to offset the surges of insulin action which occur during the course of a typical day.
Children using the insulin pump have a different paradigm. The timing of meals and snacks are determined by the pump user since insulin is being delivered “on demand” by the pump. Children with type 2 diabetes (not on insulin therapy) often have meal plan that limits total fat and calorie intake and may not require between meal snacks.
SHA: What should school staff be expected to do to help young children whose insulin dose is based on counting carbohydrates eaten from the school menu?
Dr. Ponder: The student should have a good working knowledge of carbohydrate counting. It’s not the role of school personnel to assume this duty. However, some students need to properly count the carbohydrates to be eaten in order to administer an insulin dose (by injection or using a pump). School personnel can assist the student in this process and it should be discussed during the parent-teacher meeting at the beginning of the school year. The school dietitian should be able to provide menus to parents with the estimated serving sizes and carbohydrate content. Providing the student’s family with access to school menus, which provides the amounts of carbohydrates in food items served in the school cafeteria, is extremely useful.
SHA: Are there legal requirements for school food services to accommodate students with diabetes?
Dr. Ponder: In regards to preparing special foods or meals for the student with diabetes, the answer is no. There are no “forbidden” foods in the meal plan of a person with diabetes. Virtually any food can be incorporated into a meal plan. However, such an approach demands effective communication between school personnel, the family and the child’s health provider.
SHA: How can a school handle field trips and class parties?
Dr. Ponder: The student with diabetes is to be included in all school activities. Adjustments in menus may only require the inclusion of diet colas or access to some form of carbohydrate free liquid refreshment. Even small portions of cake and ice cream can be worked into the meal plan. The key is to plan ahead and notify the parents that such activities are going to occur and what foods are expected to be present. With this information the student and family can make appropriate adjustments to participate to the fullest.
While on a field trip, supplies should be brought along to allow the student to perform any self care tasks that might be necessary during the excursion (testing equipment, insulin and syringes, and a source of fast acting carbohydrate for treatment of low blood sugar). Short trips of 1-2 hours may only need testing equipment and a source of fast acting sugar to treat hypoglycemia.
SHA: Some parents want their child to self check his/her blood glucose in the classroom but the teacher is uneasy about blood or doesn’t want to upset the classmates or others think all health procedures belong in the nurses office. What should be considered?
Dr. Ponder: Possible exposure to blood in the classroom is an appropriate concern for teachers, not only for themselves but between other students. The risk of blood borne pathogen exposure is minimal. Current blood sugar testing methodology requires only minute amounts of blood (1-10 microliters) and can be performed on sites other than then fingers (so called alternate site testing). Nevertheless, this is a topic to be discussed at the parent-teacher meeting. The right to test is protected by law; the location where the testing is to be performed is subject to school district policy. Middle and high school students who may be required to go to the nurse’s office for diabetes care should be provided a laminated “nurse hall pass” that can be used to avoid unnecessary confrontations with school personnel unfamiliar or unaware of the student’s diabetes self care needs.
SHA: Should students have to carry their glucometers to school every day? What are the pros and cons of using one school-owned glucometer on all students and staff with diabetes?
Dr. Ponder: Pros: 1) School nurses can become more competent with one testing method compared to many. 2) There is the opportunity for consistent quality control. 3) If the student has only one meter, it reduces the risk of damage incurred by transporting the meter to and from home and school. Cons: 1) Individual lancing devices are still needed for each student. 2) The student’s family needs to obtain additional sets of strips, perhaps two different types of strips (since each meter uses a different type of strip). 3) Parents might feel uncomfortable that others are “borrowing” from their child’s equipment supply. 4) Some insurance companies may not cover the school’s testing equipment. 5) Risk of cross contamination.
There are numerous brands of meters and each may have specific features that make it appealing to the student or their family. Proper meter use requires that periodic quality control be performed with high and low control solutions. Furthermore, alternate site testing can only be performed with certain meters. These reasons, plus the risk of blood borne infection are reasons not to share use a school owned meter. Many children with diabetes have more than one meter device in the home. Typically, the child will have a dedicated meter for use at school. There are instances where the family may only own one meter device and may fear risking transporting it to and from school. Students should be individually assessed for the ability to carry their testing kits with them instead of having these items kept in the nurse’s office. Current management of diabetes expects students to be able to test multiple times each day. It’s counterproductive to good diabetes management to separate the student from his/her testing equipment.
SHA: What is the minimum expectation for disposing their sharps (lancets, needles)? Should students clean glucometers at school?
Dr. Ponder: Parents should provide a proper sharps container for the school if this is not supplied by the school. A full sharps container should be closed, sealed and disposed of per state sanitation policy. Used test strips can be disposed of in the regular trash and should not be placed in a sharps container. Newer meters use strips which draw blood into the test chamber. Some older devices use optical readers which can become obscured by dried blood or strip holders which are reused. Proper care of these meters following manufacturer guidelines is crucial to obtaining accurate results. If the student is competent to perform this skill, it should be allowed. Otherwise, alternate arrangements for cleaning will need to be made. This is another topic to discuss at the parent-teacher meeting.
SHA: What are some pointers for scheduling physical education and lunch times, especially in a small school where we don’t have much flexibility? How do we minimize episodes of hypoglycemia (low blood sugar)?
Dr. Ponder: Ideal blood sugar control in diabetes comes from daily balancing food intake with insulin. There is some leeway in the time that a meal must be consumed. It would be best to discuss this at the parent teacher conference and possibly include the school counselor, who might need to restructure the student’s class schedule. However, insulin doses by injection are typically taken in advance of a meal. This sets up the possibility of a mismatch of too much insulin action with too little food. The end result can be hypoglycemia. In most circumstances, exercise acts to enhance the action of insulin. The duration and intensity of the exercise play key roles in determining the effect on blood sugar levels. Therefore, consistency in day to day scheduled activities can be invaluable to optimal control. Snacks are sometime needed prior to PE, whereas if PE occurs after a meal such adjustments may not be necessary. Diabetes experts recommend testing blood sugar prior to and after any strenuous activity to determine the impact on blood sugar levels. What's the bottom line? Eat on schedule, snack for exercise and monitor blood sugars to monitor overall effectiveness.
SHA: What is a basic plan (or algorithm) for managing low blood sugar? Low blood sugar is defined as less than 70 mg/dl
Dr. Ponder: Low blood sugar is a fact of life of any person with type 1 diabetes and many with type 2 diabetes. Recognizing low blood sugar when it occurs is the real challenge for school personnel. Although any symptom can be associated with low blood sugar, school staff should discuss signs and symptoms of hypoglycemia with the family during the parent teacher conference. Common symptoms include pallor, trembling (described by the student as “shakiness”), rapid pulse, sweating. Behavior may often change, including unusual sleepiness, slurring of speech, or frank confusion. If hypoglycemia is suspected by signs or symptoms, but no testing equipment is available, school personnel should treat for hypoglycemia. Treatment consists of providing 15 grams of rapidly absorbed carbohydrate. Examples of proper treatment include 4 ounces of fruit juice or 1/3 of a 12 ounce regular cola drink. Eight ounces of sport drink (e.g., Gatorade) is also acceptable. Wait 15 minutes and test the child’s blood sugar and retreat if blood sugar is below 70 mg/dl. Failure to treat can result in unconsciousness and frank seizure activity. Never send a child with suspected hypoglycemia alone to the school nurses office. The student should be sent in the company of an adult. It could be disastrous.
SHA: Who’s responsible for administering glucagon if a child is unconscious or vomiting? How is it administered and what else needs to happen?
Dr. Ponder: Glucagon is a hormone preparation used to
induce the body to release stored sugar into the circulation. It should
only be used in cases of severe hypoglycemia when the student cannot safely
take food or drink. Nursing personnel should be comfortable with the preparation
and administration of this drug, which is typically given by subcutaneous
injection, like an insulin shot. A glucagon emergency kit is easy enough
for anyone to administer and requires no specialized training. Ideally,
the school should have at least 3 persons capable of administering the injection.
None have to be a nurse since parents are taught how to do this in the home.
Glucagon is safe and there is virtually no risk of allergic side effects.
Students should receive 1 mg. Its effect may not be apparent for up to 10-15
minutes. During this time, it is appropriate to call 911 or local EMS for
severe hypoglycemia, since glucagon alone may not always raise blood sugar
level in some patients.
The child may vomit after a dose of glucagon is given. Position the child
on his/her side to prevent aspiration. When the student regains consciousness
and blood sugar is rising, begin feeding carbohydrate foods or beverages.
SHA: If a student has testing supplies at school for checking ketones, what is the typical action plan?
Dr. Ponder: The current recommendation is to monitor urine (or now blood) for the presence of ketones during any illness or if blood sugar levels exceed 300 mg/dl. If high blood sugar and ketones are present, special guidelines known as “sick day” rules are to be implemented. These guidelines can be part of a students care plan and should be discussed in advance. Both written and video materials care available for reference.
Generally, children with high blood sugar and ketones need increased water intake and supplemental insulin with frequent monitoring. The exact amount of supplemental insulin will vary from situation to situation, but the general rule is that more, not less, insulin is required. Therefore, if ketones are present, fluids intake should be increased and the parents should be notified immediately to discuss the need for supplemental insulin. If blood sugar is high but ketones are negative in the urine or blood, then sugar free fluid intake should be increased and the blood sugar should be rechecked in two hours. Parents do not need to be notified in this situation. In each case, more frequent testing should be performed until the blood sugar levels are back to desirable levels, and ketones are completely cleared from the child’s system.
SHA: More students are getting insulin pumps. Who is a good candidate for a pump? What are school nurse responsibilities and campus staff duties? Can the student take full PE wearing a pump? What if the parent doesn’t send supplies?
Dr. Ponder: There has been a tremendous surge in the use of insulin pumps in school age children with diabetes. Age is no longer a primary determinant, but rather attitude and interest in wearing and using the device properly. A supportive family is essential to good pump outcomes. An ability to problem solve is also invaluable. School personnel should have a basic understanding of the pump and how it works. For example, the pump cannot measure blood sugar levels. The pump delivers insulin which is either preprogrammed (the basal rate) or on demand (bolus) by the wearer. School personnel may need to assist the younger student in administering the proper insulin dose whereas the adolescent may be more independent. Pump use does not preclude contact sports. Either the pump or its infusion site can be protected, or the device can be temporarily removed with appropriate precautions. The diabetes care provider can assist in developing a plan for short periods of discontinuation without compromising control.
Failure to provide extra pump supplies for school use can become a major problem if the child begins to develop ketones, or if the infusion site becomes detached from the student. Since ketosis can develop after only a couple of hours off the pump, it will be necessary to call parents immediately so a new site can be inserted. This process takes only a few minutes to perform and can be done by older students while younger ones will definitely need help. Parents should discuss pump issues during the parent teacher conference.
SHA: We hear about type 2 diabetes in younger ages, usually those who are obese. I thought that was the type that older people develop and take pills for. What is happening that students are being diagnosed with type 2?
Dr. Ponder: Type 2 diabetes has reached epidemic proportions in children compared to just 10 years ago. Much of this is associated with the steep increase in childhood obesity. Many children with type 2 diabetes can be managed with oral medications, but others may require insulin therapy to maintain effective control. Exercise and changes in eating habits are vital to improving control and perhaps even allowing temporary discontinuation of insulin therapy, but only with close medical supervision. Many of the factors predisposing children to weight gain (fast foods, junk foods, less physical activity) all contribute to the rise in type 2 diabetes in children. There is no end in sight unless fundamental changes are made in the daily eating habits and activity schedules of at risk children. All persons can help by lobbying to keep physical education in schools at every level.
SHA: What is Acanthosis Nigricans (AN)? What does the school nurse need to know about AN?
Dr. Ponder: Acanthosis nigricans is a dermatologic condition characterized by dark, thickened skin over body parts exposed to constant flexion or friction (e.g., the neck) Acanthosis has been associated with the presence of insulin resistance, the process that provides the foundation for the development of type 2 diabetes in adults and children. Most children with Acanthosis are overweight and AN is but another “risk factor” for the development of type 2 diabetes. Because it is easy to visualize, it has become a screening tool in some Texas school districts for the possible presence of diabetes. However, less than 1% of children with AN have diabetes at the time of screening. The rest remain “at risk” and should be checked medically for development of diabetes every year by their doctor. Currently, there is no formal position statement on what, if any, interventions should be considered other than yearly testing for diabetes. However, many overweight children with AN are hypertensive, and may have problems such as obstructive sleep apnea. Some adolescent girls with AN may have symptoms of the Polycystic Ovarian Syndrome, including hirsutism, oligomenorrhea, acne, and a masculinized appearance. Any child with AN and obesity should be seen by their primary physician for a medical evaluation to evaluate the student for the presence of type 2 diabetes, hypertension, dyslipidemias, liver abnormalities (steatohepatitis), and sleep disturbances ( obstructive sleep apnea).
SHA: What can be done to reduce the risk of developing type 2 diabetes as youth or adults (like staff in our schools)?
Dr. Ponder: Weight maintenance and regular physical activity are the keys to type 2 diabetes prevention in any age group. A critical look at the foods served in the school cafeteria and in its vending machines can give an insight as to the nature of the problem we face now. The nutritional “IQ” of the average student is nil. Schools should implement nutrition education in the curriculum. Given that over 20% of children are overweight, the need for programs that raise awareness and provide solutions should be apparent. School physical education programs which promote daily physical activity should also be encouraged for all students. Although a person inherits a risk for developing type 2 diabetes, but this does not necessarily mean it will be their destiny. If weight is maintained within acceptable norms for age, along with regular physical activity, then all is being done to manage this risk. Medical therapies to prevent type 2 diabetes are on the horizon, but are still under development and investigation.
Remember…your body will not change overnight but every change you make can improve your health!
Contact Information
The Driscoll Children’s Hospital Diabetes Team:
Jennifer Amaral
Endocrinology and DiabetesStephen W. Ponder, M.D. C.D.E.
Endocrinology and DiabetesSusan Sullivan, RN, CDE
Phyllis Secraw, RN, DE
Melissa Claire, RN, DE
Meaghan Wickersham, RDChildren's Diabetes and Endocrine Center
4th Floor in the Joseph M. Sloan Building
3533 S. Alameda St.
Corpus Christi, TX 78411
Clinic appointments: (361) 694-4986
Business Office: (361) 694-4864
Office Fax: (361) 694-4832
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