Guidelines for Insulin Management of Diabetes in School
By Janet Silverstein, MD and Shannon Patrick, ARNP
Print version (PDF* 321k)
Introduction
Diabetes affects 1 in every 400–500 persons
under 20 years of age. Management
of diabetes is essential while the child is
at school. The school nurse is an essential
member of the child’s healthcare team,
which also includes the child, parents,
teachers, other school personnel, and the
diabetes medical team.
What is Type 1 diabetes?
Type 1 diabetes (T1DM) is caused by
autoimmune destruction of the beta
cells in the pancreatic islets. This autoimmune
process is triggered by (poorly
defined) factors in genetically susceptible
individuals. Symptoms of new-onset
or poorly controlled diabetes include
weight loss, polyuria, polydipsia, polyphagia,
abdominal pain, nausea, vomiting,
and blurred vision. Children with
T1DM must be treated with subcutaneous
insulin, as their pancreas makes
little or no insulin.
Several advances over the past decade
have revolutionized treatment of diabetes
in youth. Evidence has shown that
frequent self-monitoring of blood glucose
(SMBG) and insulin administration
three or more times a day or use
of an insulin pump that provides continuous
subcutaneous insulin infusion
(CSII) can result in improved glycemic
control. Further, this improved metabolic
control translates to decreased
rates of diabetes complications. As a
result, there has been a proliferation of
new insulins and intensification of diabetes
management. The predominant
goal of therapy is to achieve and maintain
blood glucose (BG) levels as close
to normal as is safely possible. In order
to achieve this, insulin therapy must be
customized to fit the patient’s life style.
Most diabetes care providers now instruct
patients to follow flexible eating
patterns and activity and to adjust their
insulin doses accordingly, rather than
asking them to adhere to a rigid meal
plan and insulin dose, as had previously
been prescribed. Thus, state-of-the art
management of diabetes has both health
and lifestyle benefits.
Successful diabetes management
requires meticulous attention to the
coordination of insulin, carbohydrate
intake, and physical activity, as well as
frequent SMBG to guide treatment decisions.
It is essential that these tasks
be performed throughout the day,
and as children spend the majority of
their day in school, these diabetes-related
tasks will need to be performed at
school. This article provides information
needed by school staff to implement
the child’s diabetes treatment
plan when insulin is involved.
Physiology of Insulin Secretion
Individuals without diabetes normally secrete
low levels of insulin to inhibit glucose
production from the liver. This insulin
output maintains normal glucose levels in
the fasting state. Basal insulin secretion
normally falls during exercise to allow increased
glucose production, reflecting the
fact that basal insulin requirements may
change with physical activity and in other
circumstances in which energy expenditure
is altered.
In addition to basal insulin secretion,
under normal circumstances a large
amount of insulin is secreted to cover
meals. Meal-related insulin secretion
increases glucose uptake by insulin-sensitive
tissues and is responsible for the
disposition of ingested carbohydrate,
resulting in normal postprandial BG
levels. In diabetes, unless injected insulin
is matched to the absorption of carbohydrate
(in timing and quantity), BG concentrations will be abnormally high
or low after meals.
Modern insulin therapy attempts
to normalize glucose metabolism by
combining basal and meal-related insulin
doses to simulate normal insulin
physiology. In ideal insulin replacement
therapy, insulin would be delivered at
a low constant rate that could be easily
adjusted for exercise or other circumstances.
Additionally, meal insulin
would be given in a form that rapidly increases
serum insulin levels severalfold
each time carbohydrate is eaten.
Insulin Formulations
and Pharmacokinetics
Insulin regimens vary from fixed-dose
schedules of two to three daily injections
to flexible regimens, including multiple
daily injections (MDI) and CSII. The
properties of currently available insulin
preparations are summarized in Table 1.
Fixed-Dose Regimens
Intermediate-acting insulins
NPH insulin is intermediate acting because
the time course of its effect is intermediate
between the long-acting and
rapid-acting insulin preparations. NPH
is generally mixed with a rapid-acting insulin
analogue and given twice daily before
breakfast, and either with dinner or
at bedtime. When given before breakfast,
NPH exhibits a peak effect that occurs
approximately in mid-afternoon, which
provides the insulin effect needed for disposal
of carbohydrate eaten at lunch. Afternoon
snacks are often required because
of the late peak of this insulin. NPH may
be given at bedtime so that its peak action
matches the rising insulin requirement
observed in the early morning hours in
many patients.
Rapid-acting insulin analogues
For decades, the only fast-acting insulin
was Regular, or crystalline insulin in solution.
Its rapid action allowed use as a
meal-related dose. However, the rapid-acting
analogues have generally replaced
Regular insulin for meal coverage, as the
delayed time of onset, late peak, and long
duration of action of Regular insulin do
not match meal absorption. Regular insulin
should be taken thirty to forty-five
minutes before eating so that the rise in
circulating insulin will match the rise in
blood glucose following meals. The rapid-acting
insulin analogues have a faster onset
and shorter duration of action than
Regular insulin, and thus more closely
match the rise and fall in blood glucose
levels associated with food absorption;
these insulins should be taken immediately
before eating.
Basal-Bolus Regimens
The basal-bolus insulin regimens are tailored
to simulate normal insulin release,
with 24-hour basal insulin to decrease
glucose output from the liver and bolus
insulin to cover meals. These regimens
provide more lifestyle flexibility and less
frequent hypoglycemia than the fixeddose
regimens but require more attention
to the diabetes regimen. The basic
elements of basal-bolus therapy for type 1
diabetes include:
- attempts to achieve blood glucose
targets that are near normal
- an insulin delivery regimen that simulates
normal physiology by combining
basal and meal-related doses
- use of frequent SMBG to adjust therapy
- matching carbohydrate intake, physical
activity, and insulin doses
Timing of meals can be very flexible when
using these regimens, because the insulin
level provided by an appropriate basal
regimen will maintain BG in the desired
range until the next meal. Patients may
omit meals, delay meals by several hours,
or eat extra meals accompanied by an extra
insulin dose.
Basal insulins include glargine (Lantus)
and detimir (Levemir). The basal
insulins have very little peak action and
are, therefore, unable to handle the glycemic
load of a meal, making it necessary
to use rapid-acting analogues for
meal coverage. Lantus is typically given
once daily, although twice daily use is
increasingly common. Levemir is most
often given twice daily.
The carbohydrate content of the meal
is responsible for the immediate rise in
BG concentration; consequently, the
pre-meal insulin dose is based on the
amount of carbohydrate ingested during
a meal. In very young children and
those with variable appetites, lispro, aspart,
and glulisine may be given immediately
after the meal is eaten — when
the amount of ingested carbohydrate is
known — thus allowing for more accurate
dosing. The mealtime bolus dose is
based on the student’s pre-meal blood
glucose level and the number of grams
of carbohydrate eaten, which should be
clearly stated in the child’s Individual
Health Plan (IHP). Most people using
MDI or an insulin pump learn to
adjust meal doses for variable food intake.
The child or parent calculates each
meal dose from the planned or actual
carbohydrate intake using an insulinto-carbohydrate ratio. In children and
adolescents, insulin to carbohydrate ratios
may vary from 1 unit per 25 grams
to 1 unit per 5 grams and are adjusted
on the basis of 2-hour postprandial BG
values. For example, if preprandial BG
is in the target range, but postprandial
BG is repeatedly high, the insulin-to-carbohydrate
ratio should be adjusted.
The meal insulin dose adjustment for
BG level is done by means of an insulin
algorithm, or “sliding scale” to guide
dose adjustments several times a day.
The algorithm should be clearly stated
in the IHP. These adjustments are made
with fast-acting insulin each time insulin
is given. Because of the need for
mealtime bolus insulin and calculation
of bolus insulin dose based on BG
levels and food intake, the basal-bolus
regimens all require SMBG and insulin
injections at lunch and at other times
during the school day.
Insulin pump therapy
CSII, or insulin pump therapy, most
closely approximates physiologic insulin
delivery, with an insulin analogue given
in small frequent pulses adjustable over 24
hours, representing basal insulin production,
and mealtime boluses given based on
mealtime BG levels and carbohydrate intake.
Newer pumps are able automatically
to calculate the bolus when the BG value and carbohydrates eaten are entered into
the pump program.
CSII has several advantages over the
other insulin regimens:
- the use of only rapid-acting insulins
may have more consistent and predictable
biologic effects
- the basal rate can be quickly adjusted
to accommodate different
levels of physical activity or basal
insulin requirements that vary with
time of day
- many patients like the freedom from
injections and increased flexibility of
insulin pump therapy
It’s disadvantages include greater cost,
risk of infection at infusion sites, and
the risk of ketoacidosis if the insulin
infusion is interrupted.
TABLE 1. PHARMACOKINETIC CHARACTERISTICS OF INSULIN FORMULATIONS (TIME IN HOURS)
Type of Insulin |
Onset |
Peak |
Duration |
Long-acting |
Detimir |
3-5 |
10-16 |
18-24 |
Glargine |
1-2 |
NA |
24 |
Intermediate-acting |
NPH |
1-2 |
6-10 |
12-20 |
|
2-4 |
6-12 |
12-20 |
Short-acting |
Regular |
0.5-1 |
2-4 |
4-8 |
Rapid-acting |
Lispro/aspart/glulysine
(Humalog/Novolog/Apidra) |
15 minutes |
0.5-2 |
3-4 |
Insulin Therapy in Type 2 Diabetes
Youth with type 2 diabetes often require
insulin therapy. The specific regimen
varies between patients, or from time to
time in the same patient. Some adolescents
early in the course of type 2 diabetes
may be well controlled with a single daily
injection of glargine insulin; others may
require an MDI regimen that is virtually
identical to that used for type 1 diabetes.
School Protocols
Diabetes management in the school
setting includes BG testing, insulin administration,
and recognition and treatment
of acute complications, including
hypoglycemia and ketonuria. The child
should have an IHP in place each year,
updated throughout the school year
if his diabetes regimen changes. This
plan should reflect the child’s current
insulin and blood glucose testing regimen
and ability to participate in self-care.
This should be accompanied by a
formal 504 plan. Sample management
plans are available online and as an appendix
in the excellent downloadable
manual “Helping the Student With
Diabetes Succeed,” both available on
the National Diabetes Education Programs
(NDEP) website ndep.nih.gov/. The American Diabetes Association
also has a downloadable sample
504 plan and treatment recommendations
for children in the school setting
at www.diabetes.org.
Insulin Administration
Insulin is administered in the school setting
according to the child’s IHP for: meal
coverage, treatment of hyperglycemia, and
treatment of urinary ketones. The IHP
will specify the individualized dosage and
schedule for insulin administration, including
the insulin-to-carbohydrate ratios
for meals and snacks and a correction dosage
(sliding scale) to treat hyperglycemia.
The insulin dose will vary based on blood
glucose readings, food availability/preference,
and physical activity level. The
nurse should contact the child’s parents
or diabetes care team if insulin must be
given for ketonuria.
Opened vials of insulin will retain
potency for 30 days when left at room
temperature but will keep for 3 months
if refrigerated. Unopened vials of insulin
should be stored in the refrigerator
and will remain good until the expiration
date noted on the insulin box. All
diabetes supplies, including insulin,
should be supplied to the school by the
child’s parents and accommodations
for storage of the medication should be
thoroughly discussed.
Blood Glucose Monitoring
The child with type 1 diabetes will need
to check BG levels before meals and any
time there are symptoms of hypoglycemia.
Some children might also need to
check BG levels 2 hours after meals, and
before or after physical activity, especially
if they have a history of exercise-induced
hypoglycemia or if they are not certain of
the effect of exercise on their BG levels.
Many children need to know pre- and
postexercise BG levels in order to adjust
insulin doses or determine if they need to
snack before physical education class or
other exercise. Most older children will be
able to do such testing independently, but
the younger child may need help.
Hypoglycemia
The student with diabetes should be allowed
immediate access to testing and
treatment supplies, and be allowed to
test when he or she is having symptoms
of hypoglycemia. If the child is unable to
test, treatment of suspected hypoglycemia
should be given immediately, even in the
absence of confirmatory BG readings.
Hypoglycemia occurs with inadequate
food intake, increased energy
expenditure, or excessive insulin dose.
Symptoms may mimic those of anxiety,
with flushing, sweating, palpitations,
and tremor, resulting from release of
catecholamines in an effort to increase
BG levels. If sugar is not given early,
there will be insufficient glucose delivered
to the brain (neuroglycopenia),
with resulting symptoms of personality
change, including uncharacteristic introverted
or aggressive behavior, which
can progress to coma or even seizures if
left untreated. Although symptoms of
hypoglycemia vary from person to person,
they generally remain consistent
for an individual.
Treatment includes immediate administration
of 15 grams of rapidly-absorbed
glucose in the form of glucose
tablets, juice, regular soda, honey, or
hard candies. The child should re-test
BG levels after 10–15 minutes and repeat
the treatment if the BG is less than
70 mg/dL or the target set by the child’s
Individual Healthcare Plan. Once the
BG has normalized, a snack may be
needed depending on the child’s anticipated
activity level, time to the next
meal or snack, and insulin regimen.
Glucose gel or gel cake icing can be
placed into the buccal mucosa, where
it will be absorbed, if the child is not
responsive or is unable to swallow juice.
If the child is completely unconscious
or having a seizure, an injection of glucagon
will be necessary. Glucagon is a
safe medication, even in large doses.
The injection can be given anywhere
an insulin injection can be given. The
child should be turned to the side, as
glucagon can cause vomiting. If it is
necessary to use glucagon, both the
parent and emergency medical services
should be called.
The occurrence of hypoglycemia may
be reduced by decreasing the insulin dose on days of increased activity, testing before
and after exercise, and snacking before
activity if the child’s BG levels drop
significantly with exercise.
Ketonuria
Ketones are caused by fat breakdown,
which normally occurs during fasting
or during the stress of illness, as stress
hormones cause lipolysis. Children with
diabetes will develop ketosis if they omit
insulin injections. Untreated ketosis results
in nausea, vomiting, abdominal
pain, rapid deep breathing, dehydration,
lethargy, and ultimately, ketoacidosis.
Ketones should be tested according
to the child’s IHP, but should always be
tested whenever the child displays any
of the symptoms noted above, whenever
the BG level is greater than 300 mg/dL
(or greater than 240mg/dL in a child on
CSII therapy), or if the child has signs
of a systemic illness, such as fever and,
especially, vomiting, even if the blood
glucose is normal. The presence of moderate
or large ketones will require extra
dosing of insulin to reverse ketosis. If
the child is on an insulin pump, it also
may be necessary to change the insertion
set and give a subcutaneous injection of
a rapid-acting insulin, since it is likely
that there is a problem with insulin infusion
into the site. It should be noted
that problems with insertion sites cannot
always be detected by their appearance.
If ketones are present, the child’s
parent and/or medical team should be
contacted for advice on treatment. If the
child is not vomiting, liberal fluid intake
will help prevent dehydration and
increase urinary excretion of ketones.
The child should be allowed free access
to water and a bathroom.
Responsibilities of the Child, Parent
and School Personnel
Child
Responsibilities for the student depend
on the age of the child. The child in
elementary school may not be able to
check blood glucose levels independently
and will always need to be supervised.
Many students in middle school
and high school may be very responsible
and knowledgeable about their diabetes
care and may be able to do blood glucose
checks independently.
Older students, depending on their age
and level of maturity, may be able to determine
insulin dose and administer insulin.
All students should be responsible for
appropriately discarding supplies used for
insulin administration. The child’s ability
to perform diabetes-related tasks responsibly
and independently should be noted
on the IHP.
Parent
The parent of the child with diabetes
must be responsible for providing the
signed IHP (or Diabetes Medical Management
Plan) to the school nurse and
for meeting with the school health team
to discuss the specifics and implementation
of the IHP. An annual meeting
to put a 504 plan into effect will clarify
both parent and school expectations
with regard to the student’s diabetes
management. This includes discussing
timing of scheduled insulin administration
and indications for giving additional
insulin. The parent should
explain the insulin-to-carbohydrate
ratio and correction factor and provide
the nurse with a chart detailing the dosing.
Treatment of hypoglycemia should
be clear. Location of insulin and related
supplies should be noted.
The parent should also give signed permission
for the school personnel and the
child’s healthcare team to share information
regarding the student’s diabetes. It is,
furthermore, the parent’s responsibility to
inform the school of any changes in the
child’s diabetes regimen.
The school should attempt to provide
the parent with the carbohydrate content
of the foods served in the cafeteria
for the week and share that information
with the school nurse. If children bring
their lunch to school, the parents should
provide the carbohydrate content for
these foods to the school nurse to allow
for accurate determination of the carbohydrate-to-insulin ratio.
The parent is responsible for providing
and maintaining all diabetes supplies,
including those necessary for insulin
administration. These supplies should
be stored in a safe place in the school
and be available when the child is participating
in extracurricular activities.
School Personnel
The school nurse is the school professional
who has the responsibility for
assuring that children with diabetes
are adequately cared for, according to
their IHPs. As such, the nurse must understand
the student’s IHP, and is expected
to arrange and participate in the
child’s 504 plan. The nurse is expected
to perform the diabetes care tasks outlined
in the student’s medical plan, and
to document the timing and dose of all
insulin given to the student. The nurse
also is responsible for clarifying insulin
regimens with the parents or the child’s
diabetes care team if there is any uncertainty
about insulin dosing. The storage
of insulin and other diabetes supplies
will be under the supervision of the
school nurse. The setting in which the
insulin is given will be determined by
the school nurse, in conjunction with
the parent.
Conclusion
Diabetes care has become complex and is
likely to become even more so with emerging
technologies, including continuous
glucose sensors and increasing capabilities
of insulin pumps.
As the student’s advocate, the nurse is
expected to encourage independence in
insulin administration, consistent with
the student’s level of maturity and skill.
If a school nurse is not available at the
school, the nurse assigned to the school on
a part-time basis is responsible for training,
assessing the competence, and then
monitoring the performance of trained diabetes personnel in carrying out the prescribed healthcare procedures.
ABOUT THE AUTHOR
Janet Silverstein, MD is a member of the National
Diabetes Education Program’s Work Group for Children
and Adolescents’ With Diabetes and Professor and
Chief, Pediatric Endocrinology, University of Florida, Gainesville, FL
Shannon Patrick, ARNP is a
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